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 +2  (familymed1#4)
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Pt si an 11 oy M, 2 asdy fo nsala geoscinotn adn oers r.ttoha ngCugoih nad signezne dcipuovret of egern .cusum eeTrh is apstsnola adiargne fo cpsioou onr-lewgeeyl muus,c nda erdnegla tno.lsis

ihsT ettpain hsa a ahde oldc, thiw pnsatsloa pidr thta is aignusc his hu.cog rilitnaAv rpheayt )E( is tno teiddrec ntaiags het ioiuhs.rnRv Teh ntietap osde tno whos sinsg fo raecbitla ecntnifio cihhw oludw uqrriee itibcanito earpyht ,F() yenlma ancpmyti bmaneemr lnbgugi nda era .anip erehT si no efrve to ctindeia resev cneitifno or sunsi eesrntndes to ectinida an Xyar- fo hte seuniss si rrtndaeaw (,)D ro taht ructule fo igcrhsead wodlu aehngc nuertrc neametttr .C() esaBeuc itsh teicoinnf is mleits-efidl adn hte hidcl nca lwbo erith ,seno iusns gaavle ni het iclcni si ont nyescersa. ).(B


 +4  (nbme23#41)
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dutno'Wl ltato VA laond naoltabi oetsryd to chyuitirtoayhtm of het m?ekaaecpr Ttha ouldw neam ttah loebw teh VA neod eht rmhhyt wuold be evddopri by a rreiavtclun ,fcoi and teosh suyulal etcrae iwed SRQ oecml.xpes

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 +17
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 +2

 +7  (nbme23#11)
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aleM reptnta dnn/nssgloee.iacbrad acopleia si dcseua yb teh cesteff fo rryottehisotdnosede )DT(H on eht kins of eth cplsa. steeentoTors is eotrdevcn yb teh eznmye eeaaadhut-prsc-l5 niot .THD dstiiieFrsane a -teusracdae-5 oihbrntii, nda os lbksco teh urincdopot of HTD dan nca htal ro neve sceau msoe rarseelv fo kmae eranptt bs.ndeals rwHeoev siht esam viyitact yma olsa lruste ni gntficains auelsx eisd tseecff uingnlcid nti,ygmesocaa eicrltee fnoysudtn,ci ucoyrtelaaj oyinfn,dutcs dna raeedsdce bdiiol.

)A anlz-Dao a awek endagnro whit tinageenocrsit cftsee,f dues ni het ntametert of nteirsmsoeido nda sifyortcibc esrtba s.aesedi )C hetlrseottyeMs-onet hscytinte ,T it si desu to sulpntempe ni ooerenesttst ednyif,iecc or in hte mttatnree of eoms tresab esccn.ar )D o-Oernnxaold na iboaacln etrsodi esud to eingar h.tegwi )E Sotolaozln- rhtaneo aoianclb r,setiod iwth ltiotpaen eusd for aeyidehrrt aeeadimon.g

sajaqua1  I am embarrassed by these typos. +1
drdoom  lol +

 +8  (nbme23#25)
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heT tpanite txesbiih rommye sosl nad voicngeti empiinatrm whti aadrlug .onets emze'rlishA seiades is llk.iey Aicthcoelyenl atvicity is odwn ni erizeAslh',m os esAeCshrtea- iibonhsrti are uesd to ekma AhC rmeo i,bvlalaae tsppgoni meso of hte fetcsfe fo rz'el.ihAsme Dlponeiez is an tChe-eAassre hri.nitibo

4pr:a.su//bd3n0cBwDd0srawk/.w8/gtguth

A) -Q-Co a crfota in htomnrilocida ,POosxh ti is losa an atidiaxtonn. It is duse sa a tdeayri mpuentp,les nda si tno DAF aporepd rof het tatenmret of nhayin.gt )C l-zuieRol a lamaetgut ngtaotsian udse ot vtprene xxcttoiioyitec ni SAL asi.ptten )D ligl-eeeSin Sivtelcee M-OBA biinhotri ahtt yam be usde ni eht etttnamre fo P',sakirnnos oulthagh I ivelebe oehrt mtntaerest era erdfeeprr ehets ya.sd )E nicZ- rapntoitm rofccaot ni anym ancreitso nnludcgii rapsctontniir coftsar n(czi fnsge)ri nad ni uonwd aignehl.


 +3  (nbme23#2)
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,sicmaaetoyGn serdip aatmion,ag and nhmasdiogoyp as( lwel as lpamra )emrhteay are lal gsins of csexes gtne.seor Teh elvir ni taseitnp htiw pcetaih ssiedae si drpiiame adn os antonc alecr tnsergoe leu.tsycfniif ixS 21 zo ebser ayild 7(2 ,oz or lhaf a nlolag) is too hcmu, and si rtoseidgyn sih irle.v

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?! +6
catch-22  The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum. +12
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". +4
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

 +18  (nbme23#38)
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ehT owmrra shsow srreoprscu ot htyrrseetyoc, as wlel as rcyatogesy.kema ihTs is to hows oyu hatt eht suise 'inst ui,tencoduonrrdp cihwh eamns thta we aer ognlis RCB dan lsaeptlte reeowemhs ei edrousttcni. hTta elrsu uot D and .E Terhe is nothngi ot iecadtni ath the cihld ash mdeindtaeiss lstroiuucbes (B). At thsi itpon ew rae ftel hwti A ro C. A owldu idetican nDmdssiiteae Irnatuacvarsl tolaCgnoaui (DIC) ro tnhsigoem lri,sami wcihh ouwdl ulstre in olw elaetsptl nad BRC utb ew odulw salo see ranaomlb BRC ikle tcshtossyeci el(h"emt" )ls.cel We are clepyxliit otld ttah eth cytsyrhtreeo ear mcnrioohmorc and n.rioyoccmt Ho,erwev niuemm rtneduiocts fo seeplttla lxpaisen ti -all hte trcoentdisu of esatplelt adsle ot esmo engomharhgri and so a rpod in ,CRB nda PIT sllscalicay rseisa raetf a eerntc pupre arprtseryoi tratc laivr oni.icetfn

meningitis  Just in case anyone is wondering like I did, the low platelet count explains thethose multinucleated cells. They are Megakaryocytes in Bone Marrow Biopsy. +12
nwinkelmann  Also, don't forget that autoimmune thrombocytopenia purpura has 2 demographics: young kids, which generally resolves spontaneously fairly quickly, and then young adult females which is a true autoimmune condition that doesn't resolve. Patient's age + thrombocytopenia + essentially normal rest of heme pannel = autoimmune thrombocytopenia purprua in child. +7
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. +

 +7  (nbme23#37)
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A anrdsdat novtiidea is a eeasrmu of bibrltpoayi in gbesenrlim teh ae.ergav neO daandtsr iadoetvin on a lebl ucvre bnidrisoitut eetsrac a %76 ehcanc ttha teh nerwsa wlli eil in rhet.e Two danrsdat iievsodtna lilw carete a %95 hcne.ca rTehe tadnsdra votinsiaed arceset a 799%. eh.cnca

Tsih ittpnea sah an eaaergv of 131, and a 5%9 ieenncdocf ta -611011 samen htta hte SD is .15 . oS one itdoliaand DS wodul give us a ganre of 1.-,.5107185 odnedur to 1.8-1018

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) +

 +7  (nbme23#32)
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hTe aacuml adnse of eth pnroneh hlspe naimtani ratluub flwo by ungatdijs lnaioidt of eht rfateenf eotlerrai fo the hnrenpo. eWhn stal si o,wl ist XCO neyszme etenisyszh PG2I wichh eildta eht ntffaeer eteor.rlai sDNISA tiiinhb O,XC nlbigokc nethisssy fo GP2I dna os rtcieldnyi biiihnitng efnftera rlteoarie dianoitl. Tow sewke goa rou aettnip saw tup no bniufp,oer a neseeocvni-lt CXO rbi.inihto isTh aeld to all ehset feec,stf tgihtsun ffo oldbo luyspp ot the prhesonn, egnrcati an ytilialracf ecidndu drpo ni doblo wlof tath losko ash letvadee NBU adn iinrta,ecen btu nasaiintm hte 1:15 ato.ir

wfye/ga#3wbtoehhraa.rw2tit2aal63/rh/ha2t.16s:aupl/ho8l-m7


 +11  (nbme23#14)
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dnaoulDe stareia is leurqetnyf icsotesaad twhi wnDo ymrno,des nad si seucad nhwe eth ddneomuu sflia to ezrnilacae ngduir etndepm.velo ehT atifnn snesetpr ihwt uiosilb nmtgii,vo os we nokw taht dfoo si ta talse kgnima ti nwod to hte dudnmueo wrehe eht itnpcrcaea tudc mseptei oint eth dodeuun.m Tish neatemilis D ldo(uw psteenr ihtw noisoiulbn nmov,itgi catyiylpl a ewf sewek rfeat tirh)b nda E uwo(ld nrpseet wiht ngikcho dna viotinmg dimltieaeym on idneg.f)e

hTe peneecrs of elbi slelt us tath elib si tgtiegn ot teh ,odnuumde so ratctapxheei bliyria tasaier oeds tno seme bpsoslei .B)( eherT si ntgniho ot iaecndti that eht cidhl has na maoelloechp )C( icnes eht ednoamb si eddsdtein whti dofo ttah t'nis signaps, utb eth ustg rae istll dinies hte laomidabn ticya.v


 +8  (nbme23#43)
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In an dlyerle etiaptn wtih altiedso eavldete akaelnli paehsoashpt ml(oanr eusrm amliucc nad oppeha)ths gPs'eta isasede fo beno dlusho eb ta the pto of hte diar.fieelftn shTi esadsie si ude ot roiuasngyeldt fo cesoiattsolc nda ocletasoibts vt;yatici itrsf na tiilina lasectsoto ceiyytiavtrph pah,es tenh ecsrinead ebtlsoaost vatyitci for a xetmi,ur hnte lssetocsato u"tbor"un dlinage to tviinerrleoamnoia-z adn eccotrisl nbeo uae.plqs nI ia,dndiot itsh nac rtecae raseverotunoi ushnst in hte osneb hciwh ssrdaceee asntciser,e adnlgei to ihhg tpoutu rdaacci eailufr a( irsamli rmblope nca aeirs ni reenrvoaoiuts tusslfai ofmr oobdl )yisdi.sal On oiytglsho it lilw ahev a "oaicsm" .tnptrea

)-A esnAmauylr obne sy-tc yegalrl a urtpdoc of hicyveiatpyrt fo ces,tatsloso hist crcous moer onetf ni teh mb,sil nad sswho a scyict sacep twih oilklblna-eo iatli.don )B Agoacir-ansmo sncamaiagroo fo the nobe si n otlsma eyprlu tylci so.elni hTey cocur mero luefentyrq ni gnroeyu eplop.e C) nNaiic fineedc-cyi I nca ifnd hionntg atubo ntiiamvb B3 iediyfccen nolinvgiv .bseon B3 ifitcceden teussrl ni ellrpag,a itwh the ccasisl rheeT s'-D tadtmisrei ha(rs alnecekc on /4CC3 etmdre,mao) e,ndamtei dan radhia.re )E aeotca-srosmO odFun tolmas xeleyscuilv in yrnogue elpope, tsih ebno hwgotr ccrsuo ta teh thgrow aetl,p ylacriltuarp ta teh mliparox nde fo het bita,i dsilat end fo the mu,rfe or oirmlxpa end fo teh surhuem i(n eht gonl sbnoe nordua your eesnk or ta oyru e)usshl.odr tI hsows a erlg,a lsdoi ringogw mssa ttah aym eaisr eht imuotesper ni a susrnutb e'ontsnaCdrmat/p .enartlgi )F otirsPcat aiaroc-cmn rrae ofr nigeb noe ,of fi not the nylo tsacettmia oben rnecca atht si puylre tsooc.aitelbs

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. +2
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. +3

 +4  (nbme23#36)
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mreuS sceksnis si a peTy 3 ieyityevpshsitnr aoirtcn,e in hiwch het dybo pssrenod ot ctiianeng daicelm sucnbsaest dan dropesuc nsa.tdbieoi eTshe eibtisodna in lrtaciounci etnh bdin ot teh tinneagic dgrus nda ste off eht enmplecotm s.edccaa muohetiadR aiirhstrt is oals a eypT 3 nrviiessetythipy reicaon.t

A) ssAtopoip fo crpms-haoage iotsapops si gllrenaey tno a tpey of stperiysivetnyhi atcornei. B) tsaM lec eaainludont-rg thsi is prta fo a ypeT 1 hirytivispnesyte nlaxynoaa,tirsiah/cpe in cihhw stam clels bind IgE no hteri ,rsceauf dna gIE gniindb ot the tgater gneiant cndeuis a raaomfncnlotoi hcgean ni the EIg htta tsse ffo atms ecll egnndtroai.ula C) tralaNu Klreil Clle kllgin-i pyasl a yativre of o,lser uncgildin enccar oprspssunie dna tnutrsecodi fo iylvlar intecdfe sell.c fI tehy play a leor ni teys,hiesvpryniti ti is ptar of Tepy 2 HRS ni hciwh yteh owldu npsoedr to Ig on eht cell ar.ufsec )E ehelW dan afler oc-etirasn hisT is lsoa a Tyep 1 SRH.

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 +7
dinagohe23  I though NK cell killing was similar to T cell so and RA is also Type IV +5
nephcard  ,blll sdouof +3
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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rymriaP voenepinrt is an evacit tpse atekn ot aehd off or etgtiaim a es-dseia knith of instcinavoac. nI this scea, it si tyleiesfl ncadioomtiif r(ecixse)e ot elph 034-0 reya old menow tih(weg bigenra rexecesi nac gaietimt sopissteoro,o sfbtinee fo crboaie eiecexs.r)

ancydSeo nepitnvoer si rayle eoidenttc fo a se,siade oitomngrp ylrae o.nrttinveien hTsi ulcdo cenliu htgsni keli IHV itsengt eryve 6 ohs,tnm ro or aalunn mmramphga.oy

riatyreT eintnvrnoite is arehypt inmiga at ungriedc ipsmcotlcnia,o ngillwoa aslepr,e ro oiirmvgpn cntof.nui nbtseiAcen morf aclohol yma be rhee ecsbaue fo utabsnsec usbea emlosbpr, or baesuec mseo edmaag syuervpoli onde by oolhacl atocnn be npert.edve yarmilSil rfo a low deyrtahcbaro dtei ew aym eb iiggntitam het sfeetcf on mlmetbiosa atth aehv eldayar neeb d.eon

sunshinesweetheart  p 269 FA 2019 +
motherhen  [P]rimary= [P]revention [S]econdary= [S]creening [T]ertiary= [T]herapy +3
rockodude  almost picked alcohol because that may lead to fetal alcohol syndrome, relevant to women of childbearing age, but regular exercise made more sense. complete abstinence of alcohol is a little extreme for a general recommendation +
jurrutia  Abstinence from alcohol is a form of primary prevention, because alcohol causes many bad outcomes. However, exercise is more important. +

 +7  (nbme24#22)
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Teh ekys to hist reaswn are tath ti si yiralf uddsne ni son,te dna tse.mirag oneN fo hte etrho esnswar ulcdo xnilape eth mteveomn fo apni from klnfa to QLL to urst.mco heilW hte keiynd nesot does ton lulaytac eetrn eth tsur,omc the ianp acn eb reerfder to hte teitsce.sl


 +17  (nbme24#20)
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rViibo cherlao dan V. yemtulapcihrosaa rea fnuyeqetrl aseatdicos hiwt nmcoosputni of eedokunrcdo afdsooe kile fisslheh.l V. nulusiicfv si ioscetadas wthi irscakhb artwe ro aaw.terstl

A) .B e-rcesu tigesntve ndte ot ecsaosati itsh iwth aeerehdt irce at a fbf,tue gitnviom is more nmocmo ahnt ridhreaa. )B .C njeu-ji atoidascse whti coedukoernd ,ofdo ellsiyecpa h,ekcnci ro acn be contacdetr by aocnttc hitw lmaina.s It eacuss lfarntmya,imo oyobld ehrdiara, dna amy aosl lead ot ilGlnarr-euaB .norseymd C) C. rsrnfgeni-pe sa a rrslao,pout siht is aasctidoes tihw odog ahtt is arehdeet tneh elft ot griaentem ta orom treeuetaprm rof a nlog mite fbeero ioupmto.ncns tymmpSso dlieunc vomigitn nda ia.arehrd )D .S u-euras a ahet satbel ointx oepudcrd by S. suarue is ioadatsecs thiw irpad tones fo iitvnogm, mya be mcdioapneca by ararhdie. Msto fneot secadstaoi thiw dyiar torspcdu nda .etma

armageddon_oh  Perfringens is also usually a delayed response, can help in vignettes! +
jj375  Vibrio cholera and V. parahaemolyticus are usually associated with seafood. B. cereus is re-heated rice, plus the vomiting type is a preformed toxin, but the diarrhea form is not, so I guess if it was rice, this could technically fit. Campylobacter is blood diarrhea, not watery. S aureus is preformed toxin so it usually happens within a few hours of eating the food, not 12 to 48 hours later. C. perf is less commonly asked about if its not gas gangrene, but First Aid also says that it's usually diarrhea after 10-12 hours and resolves by 24 hours. +

 +13  (nbme24#44)
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shTi rsawen rstes no het nedfecrfie twebeen lteFoa and reonLu.oivc Inecrtlahat xtertomaeteh si igevn ot lbock ldfyeiroatodh ceaedrsut DF)H(R morf gkiman cilof diac tnio ,DFH and hetn unnritg that DFH ntoi FH.T Tish is oden ot tevepnr the ordioctnpu of dnnotrmaesw udortscp sesracyne rfo elomiasbmt uiinlcgdn NDA itsseny.hs vcnroouLei alo(s clleda H-f-ly5TorF)m acn be usde ot sipedste shit coudptr yb ebgin tup itno layp dmoenar.tsw See het igdarma heer: -tw-ar-cnmfwdlo.ap-egaoi/wat-go/dthneeii/du-ortyd.mrmhc:cta.-hfl/d-oeiisonm atoelF si sieldt sa ciFlo cAid, txrethemetoa enrteiefrs hwti FDHR, nad unLoiercvo is o-Fr-.m5fTlyH rheTe si slao rftheru oripidesctn e:hre d0:u8/rg.twrdhan5//p1tsDBsbc.wauwk/0g

yWh dseo htis nto yplism doun hte iactno of eeoemxah?ttrt Tish si eacubes aynm snaeccr od otn ahev eht eeducrd ftaloe arec.rri So het naesccr icpk pu etofla and tomt,rtaheexe dan eirth ADN yissnshte is eduedrc. helniwaMe orthe yhheatl clsle nca kipc up the cevrnuiooL and vtase fof smoe fo hte tswro sc.fefet ereRmebm, oinurveclo tnonac eb vgein lcn.iarttehayl

SiphelbDfeysMditcmhe/c.oisuatoui.RMtroth/hnDnvo.jaDnttuisucnwk/csre:/usw//.e/iwdxLEnLNealttpe/~eosmAttAzisstern/rehtIee


 +17  (nbme23#3)
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caeuseB the b'bays hrmtoe sah yTep 1 Dabeeits lemtsul,i it si aiubelslp ttah hyte hda edtalvee dlobo eoulcgs veells rndigu ro lyhstor oeerfb ibht.r lnuniIs odes tno crsos the ctplanae, but ueolcgs ,eosd so gudnri tirhb eth eonneat ludow avhe eenb ilgycmyr.echep Thsi dluwo ldea ot eth noenalta napescar leenirsga ,ulniins iirdgvn loescgu ntio leslc dna ngunitr wond ocgeeilgensson;u stih si hyw eht byba si lcicgymyhpeo rhgit .nwo

)B eeserDdac gcgeyoln tcorain-ntenoc I tdon' nkwo het coenyglg notnraicentoc cmrdoepa ot an tdula t,naeipt tbu a scareede ni ygleongc octncninrteoa loduw dnetiiac ueelsoygolggc/nc eleresa, hiwch uowld ont eb a igcleypyomch .tesat C) ecraeedDs gnelycog etnsyhas yicita-tv ecersedda egloyngc yatnhsse tciytiav aicsdniet yergen bmcatlos,ai and would deal to iehgrh mures gesuclo v.llsee )D ardesDece semru iunlsni arconeictnotn- dadercsee msrue inliusn olwdu dela ot eihhrg evllse of luegcos ni .rsemu E) esIrdcaen umsre nsliknlii-eu tgwhro ta-ocrf GFI oesd ton dinb rnayel sa llwe ot ninisul oersrepct as niislun ,dsoe and so dwuol aveh ot be ni lrymeteex ghih otcenannositcr to aveh hist te.cfef GFI si sdseacitao with imsatco htrogw nda umlsce enolvmt.dpee

yotsubato  His glycogen concentration is high, since he's been hyperglycemic with lots of insulin until birth. +4
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. +2

 +5  (nbme23#7)
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tA kewe 8 ni glttnaseiao ldveeneoptm the pngdelovie ugt hariteens tuo of eth meyrob nad desenrogu tcnfnaiiisg rhgt.ow tA ewek 01, ihst tatosre and si rasbeedrbo iotn teh idlmnaoab ict.vya uFerail ot elyltceopm sorrbeab eht ugt dna otater olrpyrep nac rusetl ni a reunmb fo ctesed.f isacsihGtsors si aflreui ot tpoeeymlcl odrearsebb eht u,tg eivgnla oesm tceosiu hte adnoebm, twih no ve.cnoigr nenRlnlg.rei%y/et2epehcocorpmotv0tfam/.tmteope//edltF:eha

B) dgMtui llsvv-ouu orcsuc as a usterl of rtntaliaoom as eht tgu si r.bbaerodes rlidraiyOn teh ucmce is delh to the ackb fo het RQL by obrfsui dba.sn In teh nevte fo idtmug suv,llvuo ehtse ndbsa ads'(Ld dns)ba era tllis chaadtte to teh own asdpdelci uccme in eht URQ; hte oespscrm on hte ttisee,nsni gerinpvtne odof rmof imvogn huhorgt adn eonft inusacg sluboii gtimionv in r.snwonbe C) -lepOahceolm a eeftdc iiarlms ot ichgosaitr,sss ubt rcevoed by hte omleohlpcea ac.s D) mclilibaU ha-inre hte utg is enlyiret bedearobrs ni the ean,bdmo tub a ctedef in teh malrusuc llwa yloeivnrg ti lolsaw onatlme aft or ugt ot psil ghuhtro adn ubgle tou nrae the sci,buulmi tills nhebeta the nks.i sTih niarhe si yauulls eelcibdur with serrus.ep )E hlcaUra fulst-ia leafiru fo eth scuuhar to oc,esl lnsritueg ni het lgieank fo erinu frmo na iegnnpo rane teh u.isbiulcm


 +7  (nbme23#8)
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leltoLbaa si a cvnlneietsoe a-1hapl dan etaB cergndriae sat.ointnag In hte euctlr,auvsa ha1alp- tscrpeore era iloesrepbsn for craavuls ritonsciontc hchwi neiseascr oblod serry/iessmeutspc suavcarl acti.ernsse otimansgAn woldu aeesdecr eht .PB At eth sema itme, aBte-1 seoreprct ni hte hraet rae eisnroebslp fro a ositpive orniopcit nad crtoirphonco t,efefcs aiengscirn btoh haetr tare nda tclyaiottc.irn nntsaigomA ta eth a-et1B tsoeecprr ni eth ather lowdu eedarcse eahrt eat.r

A) euArolltb- rstoh natcgi ae2Bt- atgosni, esdu orf noaolbrndihciot in hte .ungls erThe is calyliypt no aregl eciysstm ntipobao.sr C) -haolPinnmeet a lvoic-esnenet phal-a1 and ap2lah- lvrereseib pocetimvtei oasa,tningt ti can be desu in neiephytrsve mnceeieegsr ro in yRnaadu nehnpn.oemo It lwuod not eftecf earht e.atr )D an-iozPsr an alaph1- tnogasi,nta ti nca be dsue to ettar pinntoehysre ro to ettar streaigmhn atssedcaoi wiht .TSPD It lwoud tno eceftf ertha ater )E plaoPo-olrn a ncnlvstcre-deeaooii- taeB ointa,atngs duse fro amyn driacca ei,ssus rfo nti,xyea nad in y.crmcoopsoheemhto This lwudo nto atfcef msicyets ulaarsvc irnse.ctsea


 +7  (nbme23#15)
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avtrntaaiPs si eth oyln nistta drug otn bmtoeilaezd by eth 04P5 stsmey ni het i.vlre aeBcsue of ht,is pasantavrti is lsao eiuqnu ni thta moer of ti si decexetr yb eth siyeknd tnah nya otreh ati,stn In ndoaidit to yrhpiiosohmtyd shti attnepi sah imdl nrela .rleifau siTh ilwl irapim icrentoex of srtpava,nait dalengi to icneadesr saattianpvr nad tsi tatolsbe,ime ainnricgse ist patloniet orf usngaci ytohma.py

B) ihslNherpas-oiit eiwhl het ntipaet is ,rmlhaeccpyeci apavntatsri oeds ton naesrcei teh nidneiecc fo edkiny otnse.s C) anitcrPiet-sa I od ont oknw fo nay iitincasngf ritiscannote ewbteen eht rpsnaace nda ant.aprsviat D) cTxoi ittap-heis lehwi tasnsit can sacue ldylim tveaeled vleir nofcuitn tste rceoss, teyh aer eyleragnl otn ecatssaiod hiwt tahpo.xotcyieit E) pyeT 2 aeitbesD mstleuli- I do ont wnok of yan tffeec atht vspaaatrtin sah on eaesbdti or aeibdset idia.tceosnm

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. +

 +18  (nbme23#5)
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iTsh tienapt ash epdrsdeiwa stocrdeunti of btoh rdaelna anslg,d hiwhc naesm htta esh illw elso tobh hre romsicrolcdioetian nad ehr udrlc.stocoiiogc ehT sols of teh cioeicmtrronadsoli adn eth fecfte no eht ydknsei si tawh si bgnie tsetde .eher Wneh ldesatenoor si gnnctufiion and aanntu,db it hsa svelrea laccrtii scfutonin on het pnoh.enr rFit,s it lseetauurpg ++a/KN AaTseP xnsoepsire on eht lroaebasatl me,abnrme gsnbaiesihlt a rongst ctlmeircclheaoe tiadnegr taht etbret bsrabos +Na, ilhew eth acdiesern ictulnlararle K+ cnencaoontitr samke it ereais to lose +K ofmr eht clel inot het e.unlm trnoloesedA loas glpauetrsue het xseepinsro of ihtpelalie isodmu alhnnecs a)E(CN on het etclciolng ,tcud gseabrbonri eorm +Na. aiy,nFll loeatoenrsd snarsecie sreepisonx fo +H esAasPT on alaaadeitt-lcrepnh slecl of the elotgcincl udc,t whhci era esebnolpsri ofr esgneticr +H hist( si artp fo aortcntcino i)ak.oalsls

Whti the sosl of rteodselo,an ew llwi ese a esersaced +N/aK+ rgntaeid adn rcsdedeae aN+ rsbnpt;aeiroo hits dslae to erddcaese seurm imduso dan aesdcrnei mrsue map.uostis tA eth same itme, otn gpxsnriese +H PAasTes wlil dale to +H ont nigbe e,etcrsed tgrecina a erom idicac nnevneoitmr p(H wlil .reaes)edc

abhishek021196  Very well written explanation. Bravo +2

 +21  (nbme23#28)
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oPrietors rdoc sorymedn cscruo deu ot iictoafnnr fo het resporoit fahl fo eth nailps ,docr rofm clconosui of teh rirospeto ilasnp rrtyea. Oru peiattn rtspeesn htwi deedrsaec nesatonis ot iinrckpp bloew teh lveel of het eeskn sa lelw sa nwaiklg whti a wsbae-eidd t,aig illeyk ncditnaiig olss fo i.toioepprpncor hTe iattnpe is asol aceimn itwh tmghepeedensyr- epr.hnilusto

grtHeeymepdnse rnsiolutphe aer yllciatpy cudsae yb an tyniailib to kema hnegou AN,D daescu yb a ackl fo aserscyne rcpusreosr nda vistamni igcnlidnu 9B (aot)lfe adn 12B laina()cmb.o fI eth tneaipt si efltao ed,iefitcn ew see edtalvee snemhytoeoci cfeyd.iienc If the ntapite is B21 i,tiedencf we ees eedtaevl otiyhmlacelmn cida dna myhoeisneotc lse.elv acHotiroyineyehsmemp nca eecnsiar simortshb.o mishoTsobr in het oirtpsreo alisnp rarety cna casue roetposir rdoc dnrs.oeym nI idndoait, aclk of iinvamt 1B2 irimasp nmilye rotnaofmi nad edlsa ot Stebuauc benmodiC rtoneig,Dneea ihchw stffcea teh alnShiimctopa tatrc gcnuntai(oc ofr reeedcasd nkcirppi i,tanes)nso tniorsiCacpol Tat,rc and olDras Clelnmad-ioMu suLscinem aTtrc iaogtn(cnuc for teh ecduedr opipotr.incoepr

A) rAioernt rdoc smdo-yern loss of otomr cnmam,do sa ellw sa lrbaetlai osls fo ahte nad ,anip eht tnaitep sah ton stol orotm c,finotun so it naoctn be shit. )B eatrnlC rocd ro-dysnme esestnrp as a ncaitmoobni fo morto adn ernsosy ossl, yllusau htiw lbredad yf.diotnunsc hsTi teniapt dose otn siadylp motor slos ro ledbrda uoisc.nfytdn C) oHcridem doe-ynsmr lAos eldlac owuarqdS-er,Bn iths is etpcelmo nyiruj to erhiet teh tlef or hrigt dies fo eth pnslia c.rdo tI seespntr wtih torom snyutiocfdn nda reeflx nnfsocyduti silaytrlpleia ta hte velle of eth oeins;l ssol fo purpe ormot comdmna blwoe teh eosnil alllstyirapie tas(pcsi ss;eapir) loss of sadlro orcmilnduca-re ninstsaoe llyiiaaltrpse at nad eblwo het ensilo; adn ssol fo nipa nad mtputrearee asoesnitn arnlctelrotylaa 2 to 3 rabvetre wbloe hte eislo.n E) rgnSeymate oeymsrnd- a nocgletian arefliu to lodeepv rtap of hte pnaisl c.odr eTh wne ensto of ptmsmyso at 28 sraye lod askme ihts an kieylnul saio.i,sdng

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

 +11  (nbme23#47)
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Crhuid-Bdia oenmdrys csourc nehw htree si couicosnl of teh pecahit ivne or het tahcipe ivne falis to adrni tnio teh I.VC Thsi acn eb acdeus by rmstohobsi fo eth eiacpht vi,ne or yb trigh esdid arhet fliarue cu(gnisa odlob to kca'b up' rereh,weyve but sit meoisnnttaafi hhrogtu teh cteipah neiv are lla hte sgsni fo r-haddiCBui r)edoy.smn ghnAtniy htta anc arecsnie hte riks fo sbistrhmoo nca hnte sneracie het skir of ahruCiidd-B moyrens.d shTi sdncueil leicytoayphm r,aev a eblrelhoupgayac taset. urO einatpt nda PV ubt siedsm ihs entimotanpp owt kewes ao.g eH wno etpsrsen ihwt sellcra csertui, na lenraged ,rlvei nad omes isgsn fo atolpr ynsein.rptohe Tsoribmsoh of eht olny lcatanaimo otipon enredtpes atth vrsceo all fo sthi is eth aectihp niev ei uro ttianep sah .hC-uidBirda memeebRr hatt riCia-ddBuh ilwl vhae a gm"etnu v"irle aepaepnarc on ssgro ltopahy.og

B) ietcHap rsr-ichois 'tis etelyirn lsipobse rou eatpitn eosd aveh taepchi soiscirhr rfo utldenear ro,asesn erohvwe hte cuate tnseo amkse hist less yleli.k )C iacatcPenr c-aniarcom aptcnarcie amcaocrin osucnitotbr fo hte cmoonm beil udtc locdu aseuc a ck'ab 'up fo lieb, aeytmtliul igcusna meso reilv maadeg dna eslaclr riuec.ts vroweeH enco niaag het intigm emkas ihst k.elnuliy )D tPlrao vein ht-boisosrm ptlrao neiv mtsihrsobo cdulo ucase smeo icnsepl tenenmrlgea nda aptrlo oshi.epenrtny oewrH,ve sit unstobcoitr dlwuo otn esacu a e,edrtn glarened relvi csaeube it is .stmpraeu )E yParrmi momtsrehicooahs- edu to a tceefd ni hdnieicp dnuopocrti, hits orin vadlrooe pntsrees thiw dkneerad iks,n nisuiln ua,ioiedgsrtnl ihactep edgmaa (tiwh eht toleatnpi rof uheoapeatrclll amccnoria) nad aehtr ieeassd icvtirrseet( ro edldait m,ctpiyyoaaordh einpegdnd on oury e)scr.ou eTh oynl eon fo thees sisgn atth uro ainttpe sah is an enlgraed vil.re

almondbreeze  FA 2019 pg 386 +

 +37  (nbme23#44)
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A adn J rtreesnpe teh irclgae sficuls,uac eihwl B nad I erpnrsete eth ueantce aufcslisc.u thrTeeog tyeh kema up eth arslod dlamnm-leiuco ialmncles tcrta, peeibnsolsr fro ppnnoiit pop,rtneeci rconpieooit,prp vianobit,r nad .seuerrsp Iutnp is tii.leaplars

C adn H meak up eth aratlel rpscoaltcoini tract osl(a caedll the lraleta rinesbearploc a,lc)ucsifsu eslibspenro fro romot dnommac fo leiaptiasrl ilb.sm

D and G esetrpren hte aeltral pnaimahsitolc a.tcrt tI is seonrlpesbi fro npai and mrureettape noutc.noidc hTe tiupn ierass ni a blim lft(e ewrol textrieym in iths ,)caes enestr ohutrgh the dloasr rtoo iepcdur(t twebeen J adn ,H) ceaedssust dna dacenss ta hte reonrtia oscsmmireu s(tju hbdeni E nda ,)F nda lynlaif ysepasns no the donecs redro reonnu in eth eartlal ialsoaipcnhmt rat.tc So teh lamnoiaipshtc ctrta is rleiossbpne ofr laatnrlotcaer ipan dan ratueretmep n.neaostis aescueB our atitepn sah lost nneiosats on eth tf,le eth eslnio is ni teh rgti.h

E nad F rae eth aiertron ocinaosticrlp ttar.c It is dlvienvo ni rmoto nrctool of amlixrpo esums,cl liyyptalc fo eht ktrnu.

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. +3
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 +2

 +11  (nbme23#39)
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,Frtis ,lcilaitryc ti si otn bdseiecrd as noi daatiniro aahp(l and beta crei)ptasl utb sa ditaronia ttah ahs an otaiiizonn .tfecef Oru afmrre hsa been out snidgnta ni hsi deif,l gikaons pu hte i.uthsnlg BVU- is avew rnoidatia thta nscudie the naimfotro fo eefr siadcalr. seheT rfee cidasarl ni utrn od aaegmd ot eht ,ecll cnlgduiin teh otanforim of nriyiimdpe semd.ir hsTi ADN madeag si het bssea orf hsi muasuqos lelc imaancco.r roF oerm no B-UV cdidune efer raildac eagmda fo N,AD m/bpip6mtevc1hntn4iw65ld.7:gs.owh5/w6bn..//u . roF more tonfraoniim no UV iordiatan rofm hte Ancreima rceCna oi,ycSet aeepls ivist -a/xa-rrpn.ilr.eurrn-icio/cucudsouiatdewwnheaeirs//t-avct/ht.mdara/snnvgaowtsovrhp--swaac-et/tcuieoa:inc

)A readeDecs ofuinntc of the ikns as a barrrei ot ir-osanccgne the paintte sha on shyrtoi gtusges epousxre to goisecanncr sedbesi UV h,gitl nad as olng as hte knis si ticant dan vitrlyalee telyhah it ohudsl nfnoctui as meos ikdn fo rebrari. )C dneresacI inrnevsooc fo -325D to -531D,2 - tish osevirnnoc ksaet lpeca in eht ekdysni iav -a-,yrahsa1ldohxplye lsoa eesersdpx in saomlargnu nda( so 35D1,2- si otenf vtadleee ni oi)iosdcsra.s ihsT uowdl otn peanlix crec.an )D sneecIdar tmiocti iacivytt rhhougt imtltsiunao fo set-oylmncea our ntetiap si odanidsge hwit smasquuo llce omianc,car otn lamoeamn. )E Iaecendsr sbituciptiylse ot kisn a-matru lwieh the mgaaed ofrm VU hlgti to claoelng oeds kame ikns eithnrn dan eomr idelrya deag,dma htis uldow ont leanxpi asomsuqu ellc an.ccaomir


 +11  (nbme23#6)
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eelBnodrri itlyoapresn ridesdo-r geselfin fo "mp,seinste" dii,scailtyu t,n-itsfoelmiaul utesabln is,htrioaenlps dan roem cmmono ni nowem tahn in .enm A moonmc fsneede asmcnmeih in tsih sioredrd is tnptl"isg"i in hwhic eoeplp rae snee sa lnreyeti godo ro tnyelire b.da enoireldrB proyielstan oidredrs si losa rpta fo eth Curtles B areoisytnlp ,erodsdrsi cwhih era teciaassdo wthi bsteusacn sbeu.a

imnotarobotbut  Suicide attempts are also commonly seen with Borderline +5

 +21  (nbme23#42)
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heT anpiett has a rrpoi hyistro fo emettryoschy tihw ailetabrl iemnposlo,o-cpgoyoahtr nda riecvdee xnteelra ameb taadniiro to eht lipvse. ehT enitpat won spylidas eyonhdrrssiohp and et,heoyrrudr iwht atldis uretlera riargnwon .aibreylatll ehT lsiekilet pnooit si htta we aer ieegns haeidosns rfmo pivorsue gyserur otcrcsnti het ertr,eus iuasncg s.hti

E) otaerhlilU nocirmaca ols(a laedcl nstoiaantrli ellc manciro)ac is olsa a oiisipblys.t What kames ihst knliuley si het coiontal: .lrtbaeali eTh orrip ttsmhcoeeyyr nda btaailrel oihnprptlaogos-oocmey udlwo leeva csar itseus no both issde of het ,yodb but teh sddo fo haluelrito acnociamr rsinagi elaaliytrlb rea ryev l.sim

)A hTe ptniaet dah a treomh,esyyct os teh ddso of tnurrrcee crveiacl amorciacn aer sola bynrldiice lo.w C) dan )D Uelharrt lcyndaoom dna uharrlet tortasilinna ecll mlolpaaip rea in eht nwgro cinotalo to cutnaoc fro liebaltra uetrhalr nowgrnari whit yoedreu.rhtr

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). +13
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
yesa  My understanding is the cancer risk with radiation is late-onset, a decade or more after the fact +

 +4  (nbme23#9)
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roFm Frits i-dA lystcphoiza epnariselotsi xheitbi iecncrtec a,acppeaern ddo ifbslee or claimag ghk,ntini nad lntearpnrseoi e.sanraswdkw Tshee sirdcebe teh eearslv reaysl fo t,loeshc eebilf ni pshciyc aiilseitb and csyat,rls dan poro eey .cntotac

A) rord-lenieB ubatenls domso twhi ymiiulv,sitp ,ft-tolulieaimsn iiiladut,ycs nda a sesne fo mntsepsie, alogn ithw a rtaeegr ohdllikeio ni wenom B) -dnneetpDe eosth ihwt na xscese eedn rof prstpou nda owl ldco-encseefnif -ictH)oCrinsi vecelsixyse lomteo,ina sekse nonetiat,t xlasuley vrocitoave,p dnroeecnc hwit apcerpaean (otra"s'c "issaeed) )D si-rsiccNstai isrg,anyoidt ,delneitt claks h,ytapem dnsedma th'e 'steb )E Soczih-di ltoyaunvr asoilc w,tlhaiarwd ltmiedi itoamoenl ,xniosprese tocnetn to eb on iethr own

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

 +9  (nbme23#22)
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HMC I unfcotin is etiglanr ot earccn sriespn.soup CHM I idasspyl sneynogduole zstdeshyine terisonp and tnpsrese etmh ot C8+D T sl.lec Teh liaefru to ypldias HCM ,I ro MHC I plsyadi fo elnf-ons a(dn by tioenxsne cua)nercso senortip irgtrseg a allreulc nmumie rspnee,os laegndi to ttdcneurois of het cle.l

The atoroemesp is dseu orf het ndeiaartogd of nowr uot, nsescn,tee or oealdfmmr erpitsn.o As rccena pleosdev, eorm nuttmisao dela ot isnceadre worng .etsnpori lOyn yb ensoxsepir fo the room,peates ro its xinrv,peso-roees anc stehe nmuatt topnersi be ddreadge fsat genohu ot nto be yleisddap yb HCM I dan dale ot eht cell nbgie idelk.l bimtorzeoB skblco teh eorm,eapost os hte uatmtn retispno aer ypadsdeil no hte r,esacfu lwligaon eth imnemu seymts to cenzioreg adn llki gicpaaoothll es.lcl

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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214736/ +27
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 proteins...so it enchances apoptosis(from uworld) +5
azibird  But CD8+ and NK cells kill via perforin! Why is this answer wrong? Is it because it's not the primary effect? +2
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." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214736/ +

 +6  (nbme23#40)
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Plaasm emmrbeasn era a dpiil e,abiryl pacyltily iwht pehhsopta eadhs no hace usercfa adn lngo bnaocr iatls no teh diiesn. hseeT aobcsrn era nle,urta nad doerung ocoiyhprbhd otesciritann for an egtcaerylenil varebaolf t.eats

nraeltIg ermbaenm rseipnot sspa utohgrh hsit pildi abyil,re dna os smtu eb aepcalb of cgnttnaieri ohtb twhi eth rpalo lesvstno of litrrllcaanue dan cteruaelxalrl p,easc sa ewll as teh hdocohyipbr erco fo eht raye.l eTh absaneertmnmr ipnrtoo entfo sah lhclaa-hpleia nrcdeoysa cfa,nimrtonoo hwit hpydoirohbc sdeuresi kile nieycgl no hte usotdie adsowtr hte rnbcoa islta iwht oralp oiamn diac uissrdee udcket n.i

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

 +8  (nbme23#14)
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hTe tpaneit tsetard crenivegi gtoalsiucprs- aosuuetsnbuc oonciaitluaatgn ,phrytea so mots llikey rieteh necdntaiatoufr hniaerp or owl lraclumeo thiwge )L(WM riehpan. aiaftnnrcdteoU aei'prnsh yarprmi cangiouiatnlota tiyilba eomcs fomr iorkngw tiwh httimiornabn III ot koblc asoactiulnog fsaocrt II nda .X

H,rewove anpireh nac osla ibdn to a etltlpea noeprit alcled eelttaPl toFacr 4 (,F4)P nfdou in nlaa.rhugapl-se hnWe ti sbind 4,FP teh ewn PFa-n4eprih lleumeco si iomicmgn.enu The muneim snpsoeer to isth rgtsaneee tPiarihnpFn4-a-e .gI Ptltaesle relyaad ehva Ig oeesrrctp no hiter e,rcasufs so henw ehets Pan--eanh4pftiir Ig retgirg teh pctsreroe no eht ,lsepttlea eesth llaesttep ntuareead.gl eTh ioulnenaartgd ickks fof tfrhrue gtti,lnoc idnegla ot a pdor toe(fn rmeo nath %)05 in ptaletel n.uotc

hoC0s/thi/wa1tc0/n3s/m.lprnP.6/2l:/wnctecMb.wg0mpi.vi


 +5  (nbme23#46)
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Tleiyrntcaecs aer umcicla aenhgticl st.agen seeacuB of is,ht in a veinelgdop tfeus or clihd ythe llwi bdni to lcaimuc ,stspidoe aynelm thtee and nsb.oe ihTs can secau beuackbl-l inoicltsrooad fo e,teth nda is nictendacoratdi in aprgentn mhertos fro htis oensar ro ni ndhelcri nrude 8 yeasr of .aeg ntidad,loAliy ihts emsa maecichl oerypprt fo binngdi to cmialcu is hyw rencita veatdlin saciton C(lcmui,a ,ueasnmgim oinr e])+F2[ veretnp soibnrapto fo lyicaser,nett and os emnsdceii iwth eshet nsoi (s,itcanda irno lanpets)notumeip dulhso be tedim otn to eiterfner ihtw is.tabonrop

mu1/iwndm.//h/wglpnb4.8ci.5t4nvos.5:whbet25p


 +21  (nbme23#18)
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zyeEnm A tasnds in orf hPoephalpioss 2,A irnuntg piolihpspodsh ni teh cell emrmnbae into adnrcoiciha .sdcia mFor hete,r neyEmz B ssdant rof nogoleCyysexca X,()CO eilwh yenEmz C dnatss ofr ax-ygopeei5nsL 5)-(.LO -5LO rouedcsp E5,P-HTE chwih is neurdt otni rtk.luoseniee ukenioteseLr ylpa a odbelu rleo ni envtes elik sathma, ebuseac tyeh asecu nhricbctoornciosnto (enes ni itsh epa)intt adn yb tganci sa cilamech ctanrasattt ofr tmnarafioylm clels, ewsho tciavtyi ilwl elcos eth raayiw ur.refth yB gicbnokl OXC uea(sblmpyr htiw na S,INA)D ew vaele omer of het atsberstu aciiracdonh adic rfo -XL5O ot ttayulimel eotvrnc iton ioes.urleenkt hTsi is hte sabsi rof eoiaahr,issrtmlatpnnia-t-n cwhhi is reyulnqtef teaaicsdos wtih laans syp.opl m(ateSsr' rt.)ida

trao/lkeuse/mFwclTp3r/witc./.w559/htrxeg9:lat4

D) orccltPniyas htnassey . )E raexhomnobT sesytanh


 +9  (nbme23#30)
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eTh tnieapt tuewednnr lmoaver fo a racelt trmou hhwic ahd mvvloneneti wthi the trseta.po Teh tpacotris eaucspl si ihrc thiw evnesr nuclndiig eht epilcv nisacplhcn evern,s a ets of tpetaiyharpsacm nevser seipslnbeor for PNS nuooiatmc oiatlrune.g ctroEenis era a smherpicayptata tocfiunn.

)A yGar rima frmo eht htyiepsmatc hcn-ia trcineoes rae a arecmpspyttiaha cfnnouti, otn eyttmchi.spa oinssimE of mrpes is a hetatpmsyci icnnuot,f and si ietedrdc by eht erifroin ipsrtgcyhao e.nerv C) dePdla-nu eht denpaudl evenr is a matocsi nevre that scrveeei iaenotsns omrf hte i,sepn pioterros cs,urtmo c,itrislo adn l,aiab as lewl as ebgin elbnsipsreo fro moes eetonmvm of hte elcipv orflo, nda uitocnleaja. D) Sioeurpr cthporgsaiy n-reev a hcyeampstti evren, isth eutncobitrs to eht itrgaphsoyc uxselp and may asol ceritoubtn ot ectahimsypt lrtnooc of sns.iemoi )E Vranlet eamri of --4SS2 sehTe mrai ruiotnecbt to eth dluneapd eer.vn

focus  Diagrams here are pretty good too: https://obgynkey.com/introduction-of-pelvic-anatomy-2/ "Point, Squeeze, Shoot" Point- erection: pelvic splanchnic nerves (S2-4) Squeeze- emission: superior hypogastric plexus Shoot- ejaculation: pudendal nerve +

 +11  (nbme23#34)
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heT esngli otsm atnrmpito thgin bouat isth srgso ghotloayp si that the aisesde is inuudor.lalmt shiT astcidine ssatetsmae mrof aidtstn e.stsi

Lievr scsabeess ear uyauls lanu,girs ielfdl wtih cmreya olylwe ,sup nad yma swho a ofsuibr cas.eplu rrChoisis eofnt hsswo a lleowy cloor ude to yttfa ehangc as ewll as igneevtearer dsenlou, wichh rea tno pnerset e.her A fcoal ulndoar aeahyirlpsp si a rnlusagi rmuot of teh ,levir nad tshi si nutdi.orlluma Hetsapiit B si a tiltle adrerh ot issgdituihn eseucba romf atwh I cna llte it acn eb lmultrdoniau ni omse aces,s btu ihts elirv sola swohs nnoe of the sslrceiso ofmr iccnohr omitfnniaalm ttah wluod yllkie naccyapom Hpe B. liayln,F we see on adkr onotdiolascir to indcteia .caortinfin

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! +
sophia  UW QId: 59 +

 +24  (nbme23#25)
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aticlCir tspoin rfo hsti qio:utnse 5 eray odl boy, sdmnipmeuusospre usebeca of o,empytehchar 2 day shytiro fo ,vrfee ucohg, henrstsos fo ,tbreha lbfriee 81.10( ,)F rsnptersoiai m/n6i,4 thiw acionyss nda eeirnagdzle sauvirlec .hars ixtensvEe ordnual iitnftairon.l

Of the iposotn deslit nyol slesaem nda ZVV evig a hsra. A ahsr rmof lmesase lyuusal ttsars ralrtylso dna sdednsce a,lldcauy dna is aflt dan r.oyatuehtsme yB n,rtacsto ZVV hnxkoicc)p(e senpsret itwh irzeaneelgd hsar ahtt uclkqyi nasnitriots omrf rcualam ot auprpla hnet ot r.iusavcle

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




Subcomments ...

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netatPi ash a aeurctfr ot eth frieoinr .rtbio hTsi can mgd 2V or rtpnae eth IR ml.cuse lyOn IR atneneptrm wlduo rmpiia sniio.v

nlkrueger  if this isn't a globe rupture than idk what is tbh +15  
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. +13  
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(535),
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Meal ptatenr necad.iessabro/ngdln poieclaa is auceds by eht tcfefes of restthnieroyeostdod H(D)T on het niks of hte .caslp eTostseenort si detvcnreo by eth zenemy ar-teuhal-sapcde5 itno THD. ieaFsdsiniter a 5cuaart-se-de rhibit,ino and so bcoksl eht iondutcorp of HDT dan anc alht ro enev seacu mseo rlservea of amke petntar sbnsela.d Hoeevrw tihs saem iicatytv mya osal ertlus in tniiascnfg xesalu isde fesefct indculnig cno,maieagyst eieretlc nucts,onfyid rcalojuatye cfnysio,ndtu and ardsdeeec d.liiob

A) -aDaozln a wkae grdeonan htiw astgoneieicnrt fftee,sc usde ni the ttmerante of doroesnimetsi adn fobcyrcstii braets e.seaisd C) rty-ltoMseenehtoest yintshetc ,T it is esud ot suelptnpem ni etntoseroste deeifcny,ci or in eth ttetaernm of omse erastb .nrcscae D) aernlnO-xdoo na nlaicaob ieostrd dues to aerign ei.whtg )E atlolSnzoo- hanteor caibanol rod,siet htwi nteliapot ueds rfo eryhiertad na.ogaideem

sajaqua1  I am embarrassed by these typos. +1  
drdoom  lol +  


submitted by shaydawn88(8),
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sI it roiaeanl-ravlt esdnttasrua acuseeb hits tentpia himtg heav HF /dt .a fib nad eflt ritala l;emn&tae-tgegnr nci tchisryoadt s&rrueep-tgs; aanuertdst uparlel iffnu?seo

sajaqua1  Basically. +4  
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(1583),
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Tish is a iacnp t.akact yonHevltepraniit opsdr pOC2 gnldiae ot a tpyraesiror a.aislolsk po2 si yreilaetvl cefndteauf ond('t aks me ?ho)w

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. +23  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +2  
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. https://www.sciencedirect.com/science/article/pii/S1110184913000615 +3  


submitted by m-ice(340),
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eTh taienpt sseem ot vahe na tfiencion deu ot ireht atdeeevl teearmretup dan lraonabm thecs -Xar.y ,wveHero their tyukeoecl otncu is o.lw nI niiddao,t teh epanitt sha ehtisitap C, wcihh is enfto acdatosesi hwti ilarims snarmointiss oreust ot IVH, keil seuiorntnav gudr su.e

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. +40  
koftawesa  CXR sounded like pneumocystis jiroveci which HIV patients are at high risk for- infections like these are usually the way HIV patients find out they have HIV +  


submitted by keycompany(311),
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naC myodsbeo hwo ndtnseurda why VPR caedrsees hiwt a diee-SfLtd fiantcr easlep gtnlhenei .em I luwod olsa aieepctpra ti if you cdoul trleae ti to rghit sdied hreta euiralf too ..(ie how odlwu it hng.)cea

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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715548/ Is a pretty good article on this. Of course the binding of catetcholamines changes depending on saturation and the response is not perfectly understood. +12  
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. +2  


submitted by seagull(1583),
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I eavh an ussei tihw hist neqioust ichwh losa flcnicsot ithw od.UWrl In rredo ot be daregded yb soemosropte het ediofdlms tpoiner uodwl eend to be seenrpt in the ylsocot rof noiu.niabut tI it daecumtlacu in teh ERR tehn owh sedo it tge adge?tg sntloHey, os ienco.f.dct.l

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 +9  


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aCn yaybndo iepxnal hsti en?o I upt tpedeear stste beucase I msadues an 3reoly--ad8 nmwao si an naluusu ogdpiamhecr for iip.hsysl

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. +5  
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. +4  
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. +12  
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. +11  
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 +13  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +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) https://www.uofmhealth.org/health-library/hw5839 +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  
imtiredofstudying  the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +  


submitted by neonem(572),
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ehT tpanite ahs owl ocotl,rsi icwhh eaussc oydb awnstg.i heT eitptna is repmgnepytedih icesn olw soilocrt ecrenssia TCAH rnicetseo rmfo eht rtip,ytiua utb tsih rseash a mnoocm rpscrroue trenpio thwi mteitomnlcaylu-gstniae rhoeonm )HS(,M os ttas'h enfot a nsig of ereith aedrnal eifrula ro an rgeectAnsHC-Ti turo.m uPt toehget,r teh hgih THCA tbu lwo slitrcoo pgiphnean erov a podrie fo 6 mnhost senam hatt het eanardl sutm be tgneigt thi by smhegiotn -- yoln tinopo eerh saw mnuotmauie litda.esairn Wdounsehea-scirreFtireh omenrsdy alos uaecss dlanrea yiisfefcnicun utb this sphaenp tl,eycua ni hte treemimaf of ssud-yohra.

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. +22  
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(40),
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Can emnooes epaxnil isth o––nIe ntd'id learly nwok hatw ot mkae fo eht abl esau.lv lyClrea she wsa agtnki oot muhc i,inulsn utb how nac you aeneeitfitdrf tcoausfiit dodrersi ofmr a ptey 1 tidcaebi how saket oot mhuc fo terih ulsinni ?sedo

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. +21  
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). +8  


submitted by m-ice(340),
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ishT nma hsa uusspl os,xruadap a ngis ni wcihh lbdoo errepuss sdesrecea iytlacdarsl indugr iipa.niornts uPslus apardsuxo si a ciscsal nsig of aledcraiirp pt.oaanmed

heWn dfuli eo(fnt odob)l sah lodoep urdnao teh eta,rh hte rtahe etggussrl to paendx dan lifl thwi do.lbo Tihs mcseobe a grgbei pbeomrl ofr teh tgihr civtnreel guirnd ,itnoarpiisn auebces het hitgr sedi fo teh htaer reecsive nasrecdei vsnoeu rnreut indgru p.anitiornis eaBceus teehr si ufdil tgenenrvpi eth htgri evlriecnt fmor exniangpd dotaur,w hte ylno htreo pceal ti can danpxe to eaocmmcdaot si yb higunps on eth m,uepst knghsrini eht esiz of hte letf t.rnlveiec hisT suaecs caeesrded PB nehw the flte rievnclet csrocttna nrdgui atth iaccdra elc.cy

sajaqua1  In addition to causing pulsus paradoxus, we see jugular venous distension, and muffled/distant heart sounds (hard to hear through the cardiac tamponade). https://radiopaedia.org/articles/beck-triad?lang=us +4  
drdoom  ^ linkify https://radiopaedia.org/articles/beck-triad?lang=us +