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Welcome to seagull’s page.
Contributor score: 1443


Comments ...

 +1  (step2ck_form8#35)

Weird question. This is a follow-up - Why would you not have an ultrasound from the previous visit? Perhaps she needs a better doctor.


 +3  (step2ck_form8#10)

"No bruits are heard over the neck"

I swear I cannot bang my face hard enough against a wall.

letsdothis  Me too. Un-friggin-believable +

 +1  (step2ck_form8#40)

Am I the only one always see conversion disorder of UWORLD as reassure and follow-up. This test is giving me conversion disorder.

seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +
seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +
bobson150  Gotta get a formal assessment before you treat I guess +2

 +3  (step2ck_form8#36)

I'm relatively sure that most people were 50:50 between bleach and drain cleaner.

letsdothis  Yeah, I spent maybe like 20 seconds on this question. I knew I wouldn't be able to reason this one out. +

 +0  (step2ck_form8#3)

I swear this changes on who you ask. I've seen it as either Isoniazid or Isoniazid + rifampin.

EDIT: 2 answers are correct here (thanks NBME!)

Per CDC

"As of 2018, there are four CDC-recommended treatment regimens for latent TB infection that use isoniazid (INH), rifapentine (RPT), and/or rifampin (RIF). All the regimens are effective."

https://www.cdc.gov/tb/topic/treatment/decideltbi.htm#:~:text=As%20of%202018%2C%20there%20are,All%20the%20regimens%20are%20effective.

letsdothis  Yes, I was going to say the same thing. Per uworld, you can do dual treatment with rifampin with isonizid for 4 months. +1

 +3  (step2ck_form8#39)

I was desperately looking for cellulitis. I never did see it. Some say I'm still looking for it to this day.


 +3  (step2ck_form7#14)

WTF is this x-ray. I would be better off pepper-spraying myself in the eyes and looking at a good x-ray than this shit.

I do not even begin to see spondlolololisthesis here.

drdoom  will you be my attending? +2

 +2  (step2ck_form7#16)

Order of treatment for acute hyperthyroid symptoms

Beta Blocker --> PTU---> Radioactive Iodine

Beta blocker wasnt an answer option but would be correct if given.

wutuwantbruv  Just as a side note, RI is contraindicated in moderate to severe Grave's ophthalmopathy as it can worsen it. +

 +1  (step2ck_form7#3)

Weakly palpable pulses with edema - what a set-up for arterial insufficency. I can see why this is stasis ulcer but it could have been way clearer in my opinion.


 +0  (step2ck_form7#3)

Basic Bitch Pneumonia - get some imaging


 +1  (step2ck_form7#11)

She appeared quite septic with diffuse rashes. I thought TSS. She also has no signs of meningitis which is characteristic of Meningiococcus.

Also the picture of the rash look like areas of blisters. smh


 +0  (step2ck_form7#26)

My understanding is that occult blood is commonly due to an upper GI bleed. Wouldn't the colon produce gross blood? I'm hopelessly lost in these matters.

krewfoo99  Yeah I am lost in this one too. Maybe colonoscopy is the right answer to rule out other serious causes of GI Bleeding (Ex: Cancer). +

 +0  (step2ck_form7#13)

Wernicke's syndrome (Vitamin B1 Deficiency)

Also known as Wernicke encephalopathy, is a neurological disease characterized by the clinical triad of confusion, the inability to coordinate voluntary movement (ataxia), and eye (ocular) abnormalities.


 +1  (step2ck_form7#24)

If you're ever unsure and it seems like it's not cancer. You slam the "Reassure" answer choice with passion.

seagull  A subconjunctival hemorrhage occurs when a tiny blood vessel breaks just underneath the clear surface of your eye (conjunctiva). The conjunctiva can't absorb blood very quickly, so the blood gets trapped. You may not even realize you have a subconjunctival hemorrhage until you look in the mirror and notice the white part of your eye is bright red. A subconjunctival hemorrhage often occurs without any obvious harm to your eye. Even a strong sneeze or cough can cause a blood vessel to break in the eye. You don't need to treat it. Your symptoms may worry you. But a subconjunctival hemorrhage is usually a harmless condition that disappears within two weeks or so. +1

 +0  (step2ck_form7#41)

Acute Tubular Necrosis due to Aminoglycoside toxicity (Gentamicin).


 +2  (step2ck_form7#38)

I literally stared at the word "cul-de-sac" for like 30 seconds and thought to myself - WTF is that? Then promptly missed the question.

P.S. it's the pouch of Douglas (rectouterine pouch).


 +1  (step2ck_form7#6)

Osgood–Schlatter disease (OSD)

Occurs with rapid growth of child. Tendon insertion commonly partially rips up some of the tibial tubercle. This is a microfracture more than failure to mineralize as the tendon fails to grow as fast as the bones - increasing tension on the insertion point.


 +0  (step2ck_form7#33)

Lead poisoning

Pt was likely in an old home. Occasionally eating paint chips because why not.

Lead Toxicity

Microcytic anemia Abdominal Pain Peripheral Neuropathy

Dx: test VENOUS blood lead

Tx: Kids- succimer Adults - EDTA


 +1  (step2ck_form7#16)

THe acid-base status of aspirin is always in the process of shifting from alkalosis to acidosis over a few hours. So relying on ABG is unreliable (in my opinion) for a quick answer.

Rule of thumb for aspirin toxicity: Fast respirations, tinnitus, kidney damage (increased creatinine).

This question she had a fast respiration rate.

---Not perfect but may help in a quick pinch-----


 +2  (step2ck_form7#16)

I love these shit pictures. It's like some old angry dude opened a text book from the 1950s and took a picture with his razor phone then uploaded the picture using windows 99.

seagull  Also, I think pseudomonas would present with hemoptysis and a much worse clinical picture. +
drmohandes  Community-acquired pneumonia. If it was a CF patient = pseudomonas. In a 25-year smoker (COPD?) = H. influenzae. +

 +0  (step2ck_form7#42)

Congestive Heart Failure. I overthought this one so hard.


 +6  (step2ck_form7#12)

This is a great example of a poorly written question. Is the infant still sedated from the surgery or ventilated? What is even happening to the surgical site? Why is analgesic therapy not already on-board post surgery? Why is this author such a douche-bag?

Perhaps the world will never know.


 +1  (step2ck_form7#43)

This was so free I thought I wandered into a Canadian hospital for a minute.


 +0  (step2ck_form7#35)

The positioning of the arm on presentation is different that what I was taught. I thought the arm was held in extension. I might be wrong here.


 +1  (step2ck_form7#3)

im convinced you cannot differentiate this from chancroid


 +0  (step2ck_form7#14)

Per 1st aid (step 1)

Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention, hypertension, paranoia, fever. Skin excoriations with methamphetamine use. Severe: cardiac arrest, seizures. Treatment: benzodiazepines for agitation and seizures.


 +2  (step2ck_form7#18)

Imagine a world where the author put things like kidney stones, constipation, altered mental status or GERD. But, no. We get the first level of hell where all these authors take fat Shits on the students. "Thank you sir - may I have another?"

nala_ula  your comments to BS questions <3 +

 +0  (step2ck_form7#31)

This is a younger pt that presents with all the signs & symptoms of GERD (retrosternal chest pain, cough, sour taste, ect). Thus, a trial PPIs is recommended

Moreover, he presents with no alarm symptoms (unexplained weight loss, dysphagia, masses, older male with prolonged symptoms, ect). If any of these symptoms are present that an endoscopy is indicated. Smoking alone in a younger pt is not an indication for an endoscopy.


 +0  (step2ck_form7#12)

SO Pulmonary Angiography has dye that shouldn't be used in CKD.

Why does the question need to be like a book in length. I was balancing like 20 ideas with her F**King diabetes and HTN. WTF

nala_ula  literally +

 +0  (step2ck_form7#2)

bilateral; i would have thought a congenital defect like hydroceles but fml


 +0  (step2ck_form7#16)

nystagmus with htn is usually a good clue. Aggressiveness is likely not to show up on stems now.


 +0  (step2ck_form7#19)

Polymyositis - Proximal muscle weakness, tenderness, Creatine kinase elevated. Normal DTR, Anti Jo antibodies.


 +1  (step2ck_form7#23)

Family therapy? Unless her issues are derived from her family in this case she needs behavioral therapy for her assumingly sexual behavior. Why would she open up in front of her dad about the dudes she being inappropriate with?


 +0  (step2ck_form7#25)

I assume the sticking a needle into her every three hours is excessive. The syrup might be easier. We don;t care about her liver anymore.


 +0  (step2ck_form7#22)

The seizure made me think that she has increase intracranial HTN and that could also explain the retinal findings. BuT I wAs WrOnG..


 +2  (step2ck_form7#20)

I came here to chew bubble gum and F**K this exam. Instead I got ran train on by all these questions.

Also, my media player didnt even work. I spent like 20 minutes trying to make it work. FML

hpsauce90  chrome has default settings for flash set to "ask"...but it doesnt always ask. i guess you already figured it out, but a quick way to do it is to click the lock icon to the left of the website address. then just set the flash setting to allow +

 +10  (nbme24#38)
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doB"ol flwo to vioruas goarsn raseinsec udingr ngeryapcn to mete hte ieredcasn coateimbl dnsee of uss.eits shT,u uosenv eturrn dna cidcara uttopu nsrcaisee dayacllmarti gnduri .nparnyceg adcCrai tutopu lralaygud esicearsn nrdgui the istrf 2 tsetermisr hitw hte egatlrs isrecnae cgoirnucr by 16 esewk of toetgs3i.an heT aisneerc in cirdaca tptuou si wlel eiasdtbslhe yb 5 ewesk of sttgoniae dan racesisne to 0%5 vabeo rngnypaeercp lveels by 61 ot 02 skewe of a.itnesogt The seri in araiccd utupto lycatiply peuaslta areft 20 skwee of ttinesaog dan maerins vteadeel iltun mtr.e The ecneirsas ni dcaacir ttuuop rae tediaasosc hwti faiignticns ceirsnsea in ostrke lomuev and erhat aert )"R(H

c13pP/.nsl8M0cgen.wpv.am/r:1//m/hiibsinow/wt2t.hCtl2c


 +4  (nbme24#46)
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I ahve an usise twhi sthi qsinueot hciwh sola cocftnsli twih UldoWr. In rdore to eb aeergddd by mptsesoroeo the ddefilmso toernip wlodu ened ot be tpreens in het yostclo orf bunoia.itun It it cademaclutu in hte ERR ehnt hwo eods ti tge e?agtgd ynstloH,e os ..fitcloedn.c

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

 +6  (nbme24#37)
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β–‘β–€β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–β–ˆβ–‘β–‘β–‘β–β–‘β–‘ β–€β–„β–„β–‘β–‘β–‘ β–€β–€β–‘β–€β–‘β–‘β–€β–„β–β–‘β–‘β–€β–‘β–ˆβ–‘β–‘β–‘β–‘β–ˆβ–‘β–β– β–‘β–β–‘β–€β–„β–‘β–‘β–‘β–‘β–„β–€β–„β–„β–‘β–‘β–€β–ˆβ–‘β–€β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–ˆ β–‘ ░░▀▄░░▄░░▐░░░░▄░░░░░░░░▐░░▄░░░░░ β–β–„β–‘β–‘β–€β–‘β–β–€β–„β–„β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–‘β–‘β–‘β–ˆβ–‘β–„β–‘β–‘β–‘ β–‘β–‘β–‘β–‘β–€β–‘β–€β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘ β–€β–‘β–‘β–‘β–‘β–‘β–β–‘β–ˆβ–€β–‘β–„β–‘β–‘β–‘β–‘ β–‘β–‘β–‘β–‘β–„β–ˆβ–€β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–β–‘β–‘ β–‘β–„β–‘β–‘β–β–‘β–€β–‘β–‘β–‘β–‘β–‘β–„β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–„β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–‘β–β–‘β–€β–‘β–‘β–‘β–‘β–‘β–€β–„β–‘β–‘β–€β–‘β–‘β–‘β–‘β–€β–‘β–‘β–‘β–€β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–„β–‘β–β–‘β–‘β–‘

paanvaannd  lollll this doesn't exactly come through on desktop but it sure is funny on a mobile browser. +4

 +13  (nbme24#28)
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A- ayirmpr otrom ctxroe = ongrw seid of ybod ifctde(i of NMU on tlef ides y)obd

B - usmaaTlh = resyson rotnaomfini utndcio - rtoom fidiestc kyullein to aietgorni mrfo ehre

C - sPon - sNC 68,5,,,7 llykei teuslr in lke"doc in nedmr"yso ro coetmpel lsso of romot fnounict no rhtig esid + aclaif esefrta.u

D. erisVm - elncrta yodb .ooatrndnoiic agDaem utesrsl ni txaaia

otN etocelmp btu yaebm pfh.luel.

yotsubato  C - Pons - CNs 8,7,6,5, likely result in "locked in syndrome" or complete loss of motor function on LEFT side + RIGHT sided facial features. Decussation occurs in medulla +2
kard  Sorry if im mistaken, Isnt A) Somatosensory? +2
krewfoo99  Yes i think A should be somatosensory. Primary motor cortex would be present in the precentral gyrus +
drpatinoire  A is primary motor. A and the gyrus at right side of A compose the paracentral lobule. +

 +1  (nbme24#25)
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I htohutg hsti wsa a etpy 1 ATR utb I asw wrngo. nyA gisunos?etgs

seagull  It looks like it was a type II RTA. The difference is incredibly subtle from the info given in this question. +13
gonyyong  He has Fanconi syndrome which is generalized reabsorption defect in PCT which leads to metabolic acidosis and hypophosphatemia β†’ can lead to rickets Also, does lead to type II RTA +15
duat98  Also the proximal tubule is the place with the highest phosphate absorption rate. That's why PTH works here mostly and a little bit in the distal tubule. +5
boostcap23  Another easy way to go about this one is the question tells you he has metabolic acidosis, the only that can happen with is Fanconi/Type2 RTA. The rest will cause hypokalemia and metabolic ALKALOSIS. (pg 586 FA) Personally thought if they were going for Fanconi syndrome they would describe a lot more symptoms for the kid like growth failure or hypophosphatemic rickets but its NBME so. +1

 +4  (nbme24#35)
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hisT intnfa hsa enogyx oixcityt deu to efer iradlac gt.eoeinran ereF adriacsl daamge eth ulng epcarnhamy igaledn to rsosbfii and slyasaipd rma(albno o.tg)rwh

link981  Per American Lung Association: Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that affects newborns (mostly premature) and infants. It results from damage to the lungs caused by mechanical ventilation (respirator) and long-term use of oxygen. Most infants recover from BPD, but some may have long-term breathing difficulty. + Prematurely born infants have very few tiny air sacs (alveoli) at birth. The alveoli that are present tend to not be mature enough to function normal, and the infant requires respiratory support to breathe. Although life-saving, these treatments can also cause lung damage. +2
jimdooder  Just to follow up on the concept, you would prevent this from occurring by decreasing the Fi02 to mid-low 90s. I believe this is tested on another form. +2

 -7  (nbme24#4)
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..B/kmoaiFidlii/irh_ri:Mijtmmdel:GoBwSse/ssetse.kinsceeywdit/s#maletipadc_g/saogtap/tyoip

I eelvieb tihs si ctalluya naedsdtisemi Bsostmaylce ude ot hte "rBoad desBa ddguBni" sa esen in eht ctrpiu.e

seagull  However, given the stain and some of the features I now see that this is most likely Crypto. THey like similar. my bad +15
mjmejora  oh what a catch! I also thought this was Blasto until you explained otherwise +
drmohandes  Blasto = broad-based budding, the two 'circles' look equal in size. Crypto = narrow-based -unequal- budding. +6
paperbackwriter  ^ I would disagree a little bit. "Broad based" and "narrow based" refer to how smushed the circles are. So narrow based is when the membrane bit they're sharing is small, and broad based is when they share a lot of membrane. So if just pinching off --> crypto, if they look stuck/have a flat membrane between them --> blasto +1

 +13  (nbme24#11)
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erhotAn aproahcp. taieeDbs uecass oinyzt-ncenam gcyonyosalilt hhwci yma teelvainyg catmip teh cuontinf of eonsunr nyimal ued to rdateel dbloo psyulp onmag trheo snti.gh heTes atlyylcesgo tispsedo pcyltlayi uoccr rirylaelephp at eth lges. ehT lnyo ereilhrppa reanws iohcce swa a rtccioneop in the eg.ls all eth rohet srnwea ceohcis rae at tslea erom eyrnallct odcelta hwti rrleag obold pulisspe.

,ignAa nto feterpc but a ywa ot senaro tuo thsi arwnse btu ti sdeo .wkro

sam1  I believe this concept is referring to peripheral sensitization. Peripheral nerves that have sustained damage (such as through non-enzymatic glycosylation in DM) cause sensitization of their neighboring nerves, thus leading to lower thresholds for activation. This sensitization is thought to be accomplished through mediators such as PGE2. +6
sam1  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701208/ ^ Section on peripheral sensitization +1

 +17  (nbme24#6)
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iTsh is a ince orcphaap to nygftideiin dna eigrantt titiuaoscf rsdoe.ird

a&amccwh/tpoesd/benk+.abptgcklcttOaorio=ew:vmFblm#6ws2g?gxhhshRpXc=+8Moiq/s:t6.r=

cinnapie  Not all heros wear capes +
privwill  Mother of mine strongly believes in this method of treatment... +8
aisel1787  lmao +1

 +2  (nbme24#32)
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hhbe=spohpsttoRlgs8/ce/roa=r::cutagqgMm.Iitmdew?r.Y4hc=#etmwciltP/&+P3Mdwr

seay iadragm


 +2  (nbme24#36)
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ishT si eeirht a irycporpteh ascr or okiled. Bhto siera ued ot rossne-prxeeiov fo b.TFteGa-

charcot_bouchard  i think its a foreign body granuloma +11
curbstep  If it is then would Tumor Necrosis Factor be valid answer as TNF-a is involved in granuloma formation? +
azibird  Because it specifically asks which subsgtance THAT PROMOTES FIBROBLAST MIGRATION AND PROLIFRERATION. I believe both TGF-b and TNF-a would be involved, but only TGF-b has this effect of fibroblasts. +1

 +0  (nbme24#48)
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Teh cnsteamsi of sthi tuosienq dame me tvoim bool.d

tA tlesa one ady a nietpat wlil kolo em in het seey dan ksa " erhwe rae iiprtesdte nreobk wdno ."ta I iwll simle ta emht dan say teh" tnaslnteii aocums dan ton eth ume.dn"dou 'elThly lmesi kcba nda nhte lil' etnh il'l lkaw waay dan hiknt fo this enomtm as I mjpu mofr the nw.doiw


 +283  (nbme24#48)
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The eainscsmt fo htis tunisoqe dame em iomtv lbo.od

eOn ayd a npettia ilwl olok em in teh esey nad ka,s eherW" aer ttesipderi rekbno ?ow"nd I iwll eslmi at mteh nda say, the" slaitietnn usamoc dan tno eht ed"unmudo. lye'hlT selmi ackb adn Ill' awkl aawy dna nthki of hits temonm sa I jmpu fomr eht wwnodi.

sympathetikey  Too real. +3
mcl  how do i upvote multiple times +16
trichotillomaniac  I made an account solely so I could upvote this. +30
dragon3  ty for the chuckle +6
cinnapie  @trichotillomaniac Same +3
thedeadly96  XD made my day! +
hardly43  RIP legend @seagull +
seagull  A legend never die +1

 +67  (nbme24#49)
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ta MIB 51 nto nyol ash ehs erven hda a idoper tbu hes evnre dah a el.ma

sympathetikey  You're on fire man lol +
monkey  How the fuck is it not related to anorexia nervosa is beyond me. +4
avarkey  the blind vaginal pouch points away from it being anorexia related +3
j44n  Its actually a man, there's no DHT to to dev the external genitals. +1
am4140  @monkey - with real anorexia, she wouldn’t necessarily have boobs either. If she’s got boobs she has the nutrition to develop boobs. That was my thought. +
freckles  the patient is actually what ever gender they want to identify as. If this was a 5 alpha reductase deficiency the patient would have experienced masculinization of external genitalia during puberty when testosterone levels increase significantly. The pt most likely has Androgen Insensitivity Syndrome. +

 +7  (nbme23#5)
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ehT nnyluiedgr miemahcns is ulayuls a mprlboe thiw ceitvocnen steius due to a aclk fo ptye I eoncgll.a iTsh rscouc ni rmeo htan %90 of sasec ued to aostnmtiu ni eht 1LACO1 or 1COL2A e.gnes ehseT cteigne pbelosmr ear nofte teiedhnir morf a snorep's nrpesta ni an olasatuom mnnoitad nrnema ro rcouc via a wen u.atmiton

-Wiki

lB,saicayl dogo *ng*f*i lkuc!


 +10  (nbme23#2)
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toAnreh ywa to apohpacr tish si nakgis yoeuslrf hhcwi of stehe ellc yptes era kyelil ngeunodrig hte msto ictmiot ittavicy. heT aruetylcogn rroprsecsu era ilekyl dviingid emor ntha nesver ro olyhecpymts n(i enabces of tnoinf).ice iTsh wsa ym pcrhao.pa


 +2  (nbme23#28)
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B12 yneccefiid ealds ot edimnlaiyton of hte CLDM adn LSA pthaaswy ie(.. orresopti ocrd )s.ryemodn


 +7  (nbme23#49)
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,So 2/15T-6T/ are eth mytiaescpth vllee ofr the te.ahr heT ttslelae nainoglg rea alevrcci tsphtymeaic nagig.onl Tihs neiostqu mssee omer onircrcet ro( a hegu )epla ot m.e uBt ,eyh I konw ppeelo ilwl gersiaed.

dentist  you're right! heart rate is the only option under sympathetic control. +
drzed  The cervical ganglion is a fusion of the last few cervical levels and the first thoracic level, so it is plausible. +

 +1  (nbme23#19)
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sr_afgdpoiinnw/yg/:k//itoeeoii.hpoda)Pklriro(twigbe.

eHre is a tietll tib on rHedoago.enrppfoi ti sphle

jcmed  I'm dropping out +1
drzed  This question doesn't have to do with proof reading, even though it is mentioned. It is just saying this: you can make all the misfolded proteins you want (e.g. proofreading can be messed up), but it has no relevance to the PROGENY. Why? The progeny of a cell is dependent on DNA replication only--so long as your DNA is perfectly replicated, the progeny will come out perfect. You don't need to worry about RNA to make DNA (unless you're HIV, of course!) +5

 +4  (nbme23#34)
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ta hte ryve sta,le heret are ltplmeui arase of aecrnc givngi moes dnoicntiai taht it yambe micsat.aett


 +6  (nbme23#38)
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Tmruaa eadl ot DSR.A ARDS pledveedo axetedu amcnctauouil ni lguns hwich boguthr on mroe flom.mianntia

axsa19  Pathoma page 94 +

 -1  (nbme23#25)
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diD nnaeyo hiktn atth unaezilfn wsa ghtr?i I euddsnnrta htta Zepr-seH can aucse iuonmaepn utb ywh is hsti aenwrs beettr eorv ?aznleufin

jrod77  I believe it's the vesicular rash that gives it away. I thought it was influenza too, but i re-read the questions and I realized they included a rash which disqualifies influenza. +4
charcot_bouchard  Also h/o of immunsupression, disseminated VZV. Influenza itself doesnt cause severe disease. secondary PNA does. which u will see in elderly. usually +1

 +14  (nbme23#19)
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hiTs tatpeni si igprnitp llb.as reteBt od a rgdu crnsee cwihh eessm b.uoovis

sympathetikey  When the answer is so obvious that you pick a stupid answer instead of it. DOH +39
jooceman739  Funny thing I noticed is "he is alert and cooperative. He appears to be in pain" So he was so high that he was alert and cooperative during the basal ganglia hemorrhage +5
yotsubato  @sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that. +1
yogi  probably the "drug" have to be a stimulant or a hallucinogen which causes HTN & Tachycardia. +2
charcot_bouchard  Lol. I got the right answer but took long time +
goodkarmaonly  The patient's B.P. and pulse are raised + Bilateral dilated pupils = Most likely use of a stimulant Thats how I reasoned it anyways +
llamastep1  Bilateraly messed up pupils = Drugs (most of the time) +
targetmle  why is there basal ganglia hemorrhage? +
dul071  Wait! doesn't it take like a week or two to get the results back!?!? i chose to measure catecholamine levels because that may be more timely. but clearly i'm wrong +1
usmile1  basal ganglia hemorrhage is an intraparenchymal hemorrhage secondary to hypertension. according to FA, this occurs most commonly at the Basal Ganglia (FA19 pg 501) +1

 +2  (nbme23#38)
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Wyh si iths ont SU?H woH did you ysgu raaocpph teh enqsu?oit

joonam  I think if this was HUS (d/t a bacterial infection) the leukocyte count would be abnormal (11k<) +
yotsubato  normochromic normocytic RBC thats why. You would see schistocytes +9
vulcania  Also for HUS I would expect mention of h/o bloody diarrhea, or at least diarrhea (not URI), and mention of something to do with kidney damage. +

 +10  (nbme23#45)
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hTis si a naipc .caktat enlievttnHyiaopr psord pCO2 gailend to a seotriarryp kaosla.sil op2 si viltyreela fafutcened ndo('t aks em ?woh)

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. +21
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

 +3  (nbme23#28)
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nL.p///ig:wiceesko/airllbw_iipdtliakh.ete

ipiWiadek slilt 1#


 +8  (nbme23#49)
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nEperihinpe is the oynl G pucdeol cerotrep tcaiavrot het l.sit The rste are hitree -utnareclleirl or a reniyost nkiase ).(lsiunni

hello  intracellular* correcting in case it trips someone up +8

 +25  (nbme23#28)
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iTsh is a type II Ranle lrubauT sic.sAdio My dciMael coSlho Nerev ttghau thsi ot em. iDd uyo slao og ot ervytop emd coh?osl mI' sieprdurs tyhe neve geav us tiolet repa.p

mousie  haha mine didn't either. But they usually leave out most high yield info so, to be expected I guess. +6
yotsubato  I didnt have physiology in my medical school. None, zip, zero, none. Nor did I have biochem. They said "you learned all this shit in undergrad, youll memorize it again for step 1 and forget it promptly" and then just moved on. +9
jcmed  In the Caribbean thats 1 thing we were given... lots and lots of toilet paper +1

 +3  (nbme23#8)
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-riHenyWdegbra anotuqie = =1 P^2 + pq2 + q2^

^P2 = 0/1000,1 = 011/0

eTnh merrebem P + q = 1 ;--t---g&- 0/011 + q = 1 q( = 1090)9/

tlyLas uplg abck tnoi d-WyrbirnHegea niqtoauE :sa

2pq = eHzoeotygret arrcrie

2( x 10/10 x 9/9010 = 0021/ = 015)/

link981  I think q should be 1/100. You got p and q mixed up. +4
humble_station  Because p = 99/100, you can just make it 1. Then just do 2 x (1/100) and you get 1/50 +4
humble_station  Because p = 99/100, you can just make it 1. Then just do 2 x (1/100) and you get 1/50 +
unhappy_triad  Carrier frequency= 2pq AR disorder that occurs in 1 in 10,000 the square root of 10,000 is 100 so, q=1/100=0.01, p= a number close to 1, just use 1. plug it in the equation 2pq= 2(1)(0.01)=0.02=1/50 +2

 +10  (nbme23#48)
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yw"h notd' oyu tosp what er'uyo igdon bcaeseu ti's "diour.luics -atucal- wnasre

sympathetikey  Mam--mam. Put down the egg, mam. +16
woodenspooninmymouth  I spent sometime in Guatemala last year, and someone told me that the egg thing is uncommon. What is common is giving their children a small gold bracelet. The bracelet is supposed to prevent the evil eye, dunno how. +1
arcanumm  I think this is a terrible question, but "not a lot" of evidence to support what she was doing is what I had picked. I realize now that is a lie which must be why it is wrong: there is NO evidence to support it. +

 +1  (nbme23#39)
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'im lslti nnicoevcd shti si abireltri woleb nsem.yodr hgCnae my dmn.i

mousie  haha I picked this too bc she's 44.... isn't celiac something that would present much younger?? but I don't think IBS would cause an iron deficiency anemia is the hint they were trying to give us. +2
sympathetikey  If it was IBS, they would have mentioned something about them having abdominal pain, different stool frequency, and then relief after defecation, me thinks. +3
aknemu  I was between celiac sprue and IBS but what pushed me towards celiac's was a few things: 1. The Iron deficency anemia (I think that would be unlikely in IBS) 2. Steatorrhea (which would also be unlikley in IBS) 3. Osteopenia- I was think vitamin D deficency 4. Lack of a psychiatric history +5
catch-22  IBS is a diagnosis of exclusion. If you haven't excluded Celiac (and this can't be excluded based on epidemiology alone), you can't diagnose IBS. +12
arcanumm  I think you may have confused it with IBD, IBS would not present like this. +2

 +31  (nbme23#50)
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Wtha a teebrlri ceiur.tp Tyeh tehy evdecro up tpar fo ti thiw lien.s TWF

sympathetikey  Agreed. +11
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2
catch-22  You're looking at the ventral aspect of the brainstem. +10
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4
hello  which letter is CN IX in this diagram? +
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +

 +0  (nbme22#15)
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hTe ssam is in hte utore uppre t,uadqran sthi si yhw ti twan D.CSI cieN dan eilspm

seagull  *wasn't +

 +40  (nbme22#36)
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chiWh of eth gwiolnfol snrasoe is yhw htsi eoiqsunt si bu?ll

1) ingUs eth ordw ycli"c"c tsdenia fo ilcyicctr rfo liytrca

2) nwiKong all fo ylpgemeooidi fo lla dsgur

)3 nivgah to oesnra uot atth aienhorgntciilc efcftse are oprabylb hte rwsto rveo ahpal1 ro 1H ecfftse to no ae.ctrytin

4) ehT ilgpcnrip rensieopds fo snguyidt for stweda-ey-kos no dne ot bopyalbr do geeavar no het ts.et

nlkrueger  yo, re-fucking-tweet +20
aesalmon  I agree, I picked H1 because such a common complaint for those on TCAs is Sedation, I figure it might be so commonly seen as to be the "most common" reason for noncompliance. I suppose the "hot as a hare...etc" effects would be more severe/annoying, but I didn't think they were more common. +4
fcambridge  I just like to pretend that there's a reason this question is now in an NBME and no longer being used for the test. Hopefully they realized the idiocy of this question like we all do +1
link981  Since it said cyclic, I thought of using, discontinuing, then using again. These people who write these questions need take some English writing courses so they can write with CLARITY. Cyclic is not the same as Tricyclic. +5
waterloo  Incredibly awful question. one thought I did have when deciding between anticholinergic and antihistaminic - nortriptyline and desipramine are secondary amines that have less anti-cholinergic effects (from Sketchy Pharm) so maybe that's what they were getting at? That someone went out and made a new TCA drug that would have less anticholinergic effects. +
victor_abdullatif  This isn't testing drug epidemiology; it's actually asking "which of these side effects are caused by TCAs and would be the worst to experience?" +

 +8  (nbme22#8)
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oS hlapa wsa het aerwsn so my dgiteuaf nidm ptu ."lw.e."Al oen.d oueYr' oggin to be a ord.oct llo

impostersyndromel1000  hope you dont have to write a prescription for me one day lol +4

 +58  (nbme22#35)
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dDi oynnae ened to raed ttah astl secenetn lkei 50 ismte sceebua eht ohraut frueses ot sue rteebt amrargm. uJts rr.inufagtst

link981  Author rationale: "What is grammar?" +6
qfever  Did anyone read like 50 times and still get it wrong? (LOL, me) +16
drbravojose  Actually never understand what the author saying at any time. LOL +3
alimd  Such a shitty question. Do we really have such questions on the real exam? In my opinion they just throw junk question to those assesments +
nootnootpenguinn  Oh my goodness- thank you! I was so mad at whoever wrote this shitty question! (Got it wrong lol) +

 +23  (nbme22#30)
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tuo of ryciistuo, hwo amy pleope enwk h?tis on(td be syh to say yuo ddi ro d)dnti?

yM oeyptvr uceonitad itd'nd gniinar tish in .em

johnthurtjr  I did not +1
nlkrueger  i did not lol +
ht3  you're definitely not alone lol +
yotsubato  no idea +
yotsubato  And its not in FA, so fuck it IMO +1
niboonsh  i didnt +
imnotarobotbut  Nope +
epr94  did not +
link981  I guessed it because the names sounded similar :D +14
d_holles  i did not +
yb_26  I also guessed because both words start with "glu"))) +27
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1
jaxx  Not a clue. This was so random. +
ls3076  no way +
hyperfukus  no clue +
mkreamy  this made me feel a lot better. also, no fucking clue +1
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4
djtallahassee  yea, I mature 30k anki cards to see this bs +4
taediggity  I literally shouted wtf in quiet library at this question. +1
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21
drschmoctor  Is it biochemistry? Then I do not know it. +4
snoochi95  hell no brother +
roro17  I didn’t +
bodanese  I did not +
hatethisshit  nope +
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1
waterloo  Nope. +
monique  I did not +
issamd1221  didnt +
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1
amy  +1 no idea! +
mumenrider4ever  Had no idea what glucosamine was +
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1
surfacegomd  no clue +
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +
chediakhigashi  nurp +
kidokick  just adding in to say, nope. +
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1

 +7  (nbme22#43)
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TisH nqoeitus si just atiicclr n.kiihntg Teh anslerad ear brlallyteai nad aicmllysyrtme s.amll lAl retho srnwae oicsceh rea ont ilkyel ot eb neve lbel.trlayia eCarcn w'nto lyeqalu redaps ni ftrepce tsmeyrmy nro tcsnieufio eascsu weihl anngtaimiin eth alnadre iteeuarcth.rc

slim23shady  Will TB be the answer if they'd mentioned the patient from developing world? +
step1soon  Autoimmune adrenalitis aka addisons disease β†’ adrenals atrophy common cause: 1. developing world: TB 2. Western world:autoimmunne FA 2019 page 334 +14
drschmoctor  FA 2020 p 349. +
drzed  I think the cancer reference (C) was with respect to an ACTH secreting tumor, which would symmetrically and bilaterally HYPERTROPHY the adrenals +2
drzed  ^Just kidding, it says metastatic. My bad! +1

 -2  (nbme22#21)
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sThi is a heilodliok r.tiao +=RL -pieS/sne1fcS

Ayn lveau gretrea anth 01 r(ep ristf ai)d tinddceai seulnfss"ue of ioatscingd st"et hicwh si acbroeplma ot PPV ngr(ilu in a d.)z tPoni "A" is eth osetlsc ramk to weehr 10 hodlus eb on the Y sa.xi

brise  The question is asking what point would be the most likely to rule in cancer, and high specificity when positive rules in cancer. The highest specificity value is A, bc the the X axis shows (1-specificity)! +5
hello  brise is correct. Knowing the LR+ value = 10 does not help in this situation because estimating where "10" should fall on an axis is arbitrary. The way to approach this Q is to know that a high specificity is will mean that a positive result is very very likely to be a true positive. In theory, suppose that the specificity was 0.99. This is 99% specificity. Then, you look at the graph. The X-axis is "1-specificity." So, suppose the best test has a specificity of 99%. Then, calculating 1-specificity = 1 - 0.99 = 0.1. You would then chose the datapoint that corresponds to having an "X-value" that is closest to the origin. In this problem, it corresponds to data point "A." +3

 +23  (nbme22#18)
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ehT oarhstu ntwe tuo fo eithr yaw ot infd hwte wotsr ohtop fo a nrulmogaa thye du.lco ehT wtehr no a etsm ahtt geugssts htta ti wdulo eb gaartuinnol uies.t tBu lltite ddi ew .ko.nw.

amorah  I was between granulation tissue and granuloma. Then ruled out granulation tissue because this is a 10 week old wound. Assuming normal wound healing, granulation tissue would be replaced by type III collagen/resolution by 10 weeks. +17
sbryant6  Got this right because the exact same question is in Uworld. +
dubywow  Got baited... took my eye off the ball (and onto that worst photo ever) and missed the Ten week part. Granulation for the "L". +1
groovygrinch  Anytime they go out of their way to mention sutures, my mind goes right to granulomas +
beto  there are multinucleated cells(minimum 4). this helped me to choose granuloma over granulation tissue +4
haniainabox  Also - pathoma pg 21 (ch.2), granulation tissue consists of fibroblasts, CAPILLARIES, and myofibroblasts, so I think with granulation tissue you'd see a lot more BV and blood +1

 +1  (nbme22#24)
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mI loas nincodvce ocgnbkli 2L-I is sola a e?nmtattre yWH si alph-aTFN the beertt awsren ?reeh

amorah  FA P120-122. Immunosuppressants for RA are calcineurin inhibitor (cyclosporine and tacrolimus), 6MP, and TNFa inhibitors (adalimumab,infliximab, etanercept). It is important to distinguish that calcineurin inhibitors block t cell activation by preventing IL-2 transcription, not necessarily block IL-2 action. Sirolimus(rapamycin) blocks IL-2 action but it is used for kidney transplant rejection prophylaxis specifically. +17
krewfoo99  in addition to the above responses, IL 1 antagonists (Anakinra) can be used to treat RA. Anakinra is a recombinant human IL 1 receptor anatagonist but less effective than other treatment modalities. +
snripper  Prednisone is a glucocorticoid (which inhibits IL-2 synthesis) is already being used with no effect. So TNF-alpha is the next option. +
avocadotoast  DMARDs: methotrextate, sulfasalazine, hydroxychloroquine, leflunomide, TNF inhibitors, Anti- IL6 (Tocilizumab), JAK inhibitor (Tofacitinib), Rituximab. You can use cyclosporine and tacrolimus to treat RA, but those aren't first line treatments. DMARDs are used the long term treatment of RA and methotrexate is often started first, and the other drugs are prescribed if methotrexate does not sufficiently control symptoms. None of the other choices listed are a part of DMARD therapy. +

 +0  (nbme22#15)
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nM/l9//c./ep4hs9.tiv.Cgntac/wr.mt8Pm6libswo/c9hpi4n:w

dArgiconc ot shti ,preap oprmsPautt hstidoiyrTi tsrsenep wthi a-TiOPnt dboin.eatsi ehT eawsrn eochic uess mhcly.eoptys oS tish is a itnarsnte Himahsotos Hse.oidmyrthrpyi oGod ucLk whit tath o!ne

seagull  EDIT: Lymphocytes are also present in this as well. My bad +1

 +3  (nbme22#41)
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plueCo aysw to tge hte s.nerwa 1. nstiesano fo the anoreitr ihgth dna eladmi egl rae by rscabneh fo het feolmra rvene ,L3( 4,L ).5L 2. Senci het iotraner ghith si aefdtcfe eth ltlpealra leefxr si lyeilk ftecaefd ihhwc is a cnbarh fo .4L

medschul  Isn't the femoral nerve innervated by L2-4? +4

 +6  (nbme22#44)
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fI uoy tdn'o onkw htaw cralDiomu eods leki nya arnmol mnuah. heT ucofs on twah rpinasi 'odntse o,d mnylae 'tsi eodns't fecaft TP eimt adn stom ilspl nto'd cenesrai tocnglti iplslcey(ae itwh ni.)arips hTsi si ohw I ogcil to het htigr n.wrsae

usmleuser007  If that's then thinking, then how would you differentiate between PT & PTT? +21
ls3076  Why isn't "Decreased platelet count" correct? Aspirin does not decrease the platelet count, only inactivates platelets. +4
drmohandes  Because dicumarol does not decrease platelet count either. +
krewfoo99  @usmleuser007 Because the answer choice says decrease in PTT. If you take a heparin like drug then the PTT will increase. Drugs wont increase PTT (that would be procoagulant) +3
pg32  I think usmleuser007 and is3076 were working form the perspective of not knowing what dicumerol was. If you were unsure what dicumarol was, there really wasn't a way to get this correct, contrary to @seagull's comment. You can't really rule out any of these as possible options because aspirin doesn't do any of them. +4
snripper  yeah, it wouldn't work. We'll need to know with Dicumarol is. +4
jackie_chan  Not true, the logic works. You gotta know what aspirin does at least, it interferes with COX1 irreversibly and inhibits platelet aggregation (kinda like an induced Glanzzman), all it does. PT, aPTT are functions of the coagulation cascade and the test itself is not an assessment of platelet function. Bleeding time/clotting time is an assessment of platelet function. A- decreased plasma fibrinogen concentration- not impacted B- decreased aPTT/partial- DECREASED, indicates you are hypercoaguable, not the case C- decreased platelet count- aspirin does not destroy platelets D- normal clotting time- no we established aspirin impacts clotting/bleeding time by preventing aggregation E- prolonged PT- answer, aspirin does not impact the coagulation factor cascades in the test +3
teepot123  di'coumarin'ol +

 +4  (nbme22#50)
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iThs is na mioteecnpl hdrtyaodfmii elom. heTy ntaicon enlpiomcte tlafe asptr cglniiudn mets llsce ihchw rea romstyi nda give reis ot ruuustdnterc sseti.u

kard  Can someone explain why the other choices are incorrect?, Thanks +
mtkilimanjaro  I got it wrong and put the lacunae one, I wasnt sure if hematopoietic stem cells could occur from the mother as well. If it had any other cell line i wouldve picked it. For the others: this lady has a partial mole, which has fetal parts. A complete mole has NO fetal parts. Both mole types have cyto, syncytio, and villi. Thats how I ruled those ones out +2

 +2  (nbme22#33)
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eceR/gwr.wseefin/dt/liyn.s_ki/okiipaxphtp:eo

avagVsalo Sencp.oy huMc aiseer


 +2  (nbme22#41)
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Why seapono?stun 'esH nganiegg ni na eatcvi ptros iwht an edinecsra kisr fo rtmcuaiaT nrjui.y So we arlley sutj maeuss seh tno iujredn ceebsua hte stme oetsdn eydlcrti yas she' njr?uide heeTs suesntqio leda to too nyma tpnouas.issm (in my ni)onpio

nc1992  Spontaneous pneumothorax, as a condition, is significantly more likely than a traumatic pneumothorax from just about anything but a car crash (ok maybe if he was in a fight). The car crash or a stabbing is also more probable overall but there's no point in inferring something that isn't provided +1
nwinkelmann  I picked the traumatic injury also. After reading these comments I looked into it further. Traumatic pneumos occur because of blunt or penetrating chest trauma, and I found that the MCC form of blunt trauma (>70%) is motor vehicle acidents that cause significant trauma (i.e. rib fractures) or even blast trauma. Although it didn't say there were no chest wall fractures, at the same time it didn't indicate any rib fractures, which would be most like to cause the traumatic injury pneumo in the patient's case. +1
drdoom  The stem makes no mention of trauma. +
hyperfukus  i guess the issue is that you have to assume what they mean by "strongest predisposing risk factor for this patient's condition" I think this is dumb bc the answer is completely different based on what you consider this patient's "CONDITION" to be? either way he has a pneumothorax so if you wan to know what caused that its prob him being active or bumping into someone but if you consider the etiology of the pneumothorax then its the bleb and that is from him being a skinny dude/smoker i went to this b/c he's also only 5/10 that's not tall in my head they could have been nicer and made him 6'1 at least...also i feel like i saw a lot of q's back in the day when i first learned this with a presentation of the person like tripping or something dumb but they already had the bleb and then got the pneumothorax +

 +6  (nbme22#17)
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/rhr/5rft-ysn1trjr-igeps2dntaauaupilkacs2eo/a:-/hepten-otassnsi/o0-/pe/scim05sitnanr.o3

Fruieg .2 gahhltou iugref 1 ksolo lgshikoync lamiisr

drbravojose  genius +1
alimd  there is no way to distinguish b/n eversion and inversion based on step1 knowledge +1

 -1  (nbme22#20)
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yemab noseome nca elixapn hwy sthi si alvascrau snrseico dan nto isps.se It nsodet' oimnent veref ro cesnbae fo e.vefr hTe IMR has a smlla numaot of oysenptidyh ubt ot tge csluraava ieosrnsc eessm /ddo

someduck3  Pg 455 of F.A. mentions that alcoholism can be a cause of avascular necrosis. +5
meningitis  I think the small dark area on the left head of femur and the darkened neck are the avascular sites. Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg +3
yotsubato  He wouldnt be playing golf if he had septic arthritis. Avascular necrosis is a more chronic condition that has a slow onset. +3

 +1  (nbme22#6)
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euTr avolc cords rea otnef aamgedd ni nnisgig or g.llynei sHiT sloalw PHV ot neret eht drgyleunin nedtulcae llsec. HPV 61 and 18 are momcno stesuybp htta aym uscea S.CC

meningitis  Out of all of the virus', HPV has a predilection for stratified squamous epithelium and there is no indication of vesicles(HSV) or linear ulcers (CMV)in the question stem. But with HPV you usually get a big/small (depending on time) unilateral nodule. You are correct to say singing and yelling can cause nodules but these would be bilateral in the and would appear differently. So if a question stem could easily have included that as an option: maybe irritation or something like that. +11

 +2  (nbme22#10)
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eoSypenltcm iptetsan era nbrelvulea gtniaas pslendecutaa sogrmasi.n hiWhc ncmlomyo neldciu rSetp ,Pueonm s,rasNieie .H .nneIfluaz

ergogenic22  although Pseudomonas, Klebsiella are also encapsulated, strep pneumo is more common for pneumonia in a 25 year old F without other comorbidities +5

 +48  (nbme21#2)
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! I htea hseet thwi a briungn n**Fgi* iapsnos. bsuTmh pu if uoy earge

mcl  Amen brother +1
praderwilli  Every morning: "I think i'll go over glycogen storage diseases, lysosomal storage diseases, and dyslipidemias after questions this afternoon." Every afternoon: Nah +28
mcl  oh my god are you me +1
praderwilli  I recently found a program called Pixorize. It's pretty much Sketchy for biochem. Wish I discovered it sooner cuz it has helped for a lot of the painful things like this! +6
burak  Cherry red spot basically means niemann-pick or tay sachs. Two differences between is: 1- No HSM in Tay Sachs, HSM in niemann-pick. 2- Both of them has muscle weakness but there is hyperreflexia in Tay Sachs, but areflexia in niemann pick disease. In stem cell HSM is not described and hyperreflexia noted. +4
abhishek021196  What is HSM? +
mysticsoul  HSM - HepatoSplenoMegaly. Cherry red spots think of Tay Sachs, deficient enzyme - HeXosaminidase A, accumulated substrate GM2 ganglioside. Niemann-Pick - Spingomyelinase, Spingomyelin <- which is not even a choice. FA18 Pg 88 +
lakshmi  Dirty USMLE has an incredible video that makes these super easy to get. +1
djeffs1  @lakshmi Link? +

 +5  (nbme21#36)
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e~iI7dn/kmhw.2/umg8uie//egtpwbG1d..s:wdtrt/h

nAhtero glshyitoo slied whit esblal a wfe dssoecn ago

enbeemee  what are the other labeled structures? i can discern the parietal and chief cells, but not really the others... +1
hyperfukus  yea wth is A +1

 +0  (nbme21#14)
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g10crmihc:/.Pthmin9.t/co/n2p.wsM/ta.lCli/nsve7/w8w2pb

iTsh tlercai fiasl ot tnmnoie opor ainbr nvmolpteeed ni yoHEiRrhmidPsYt. hTe orahut utms hvae mtean ot.rmiPHiYOshdy

hTsi tesnoqui tsupes em ot on en.d

aesalmon  I agree, the article you linked states "signs of fetal hyperthyroidism such as tachycardia, intrauterine growth retardation, cardiac failure, and the development of fetal goitre" I chose answer E during the exam - "Thyroid gland enlargement" Still trying to understand how they linked cretinism to a case where the mother's hypothyroidism was well controlled, and then asked for the sequelae if her TSH increased. Maybe increased TSH is supposed to indicate worsening hypothyroid - low T3/T4 needing to be stimulated by TSH? +

 +3  (nbme21#41)
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rpDeeossni si revy ncoomm in deolr aip,lspontuo eepcyllias lsefea.m oomCmn ostmypsm fo irpdnoeses cidnlue GSI E SPCA nuilcngid( imsi)nno.a sTiH iequnots wsa eyrv gvaue but ropsidenes swa edgde tuo seubeac pslee panea is omer liykle ni gewhetvroi dlemdi gdae elam.s


 +1  (nbme21#36)
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dpyoIitic sanem --- dontabiy gsinaat bdnt.aioy B llsce n'tdo have rscaefu idsbtaoein utb meer ezithsseny tmeh.

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +
seagull  I should have clarified that I was speaking about mature B cells. Thank You +3
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +

 +4  (nbme21#20)
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The neptait ahs a ifetenine.co/fvr eTh ecipurt oshws nrloam (1 itrm)ueam utrgyosnclea (l.huriptseon) The miermatu mthgi be ptra fo eth sf-fetitlh ocrciugn ni htsi i.neptta eTfr,eoehr siht si spyiml a revcieta nmemui srecsop.


 +18  (nbme21#40)
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ixiEnmnag aettpin rmfo a trosloigu liepsim okrBsen iaBs iwhhc lwdou kews hte panuooptli mena of rmeus aeur nrnoetgi yawa fmor teh erut cceaatru nme.a ne,hT ilazeer rinispeoc si ndeenpedt no tliasiattsc wP"re"o cwhhi is cenierdas sebda on the eisz of het tpiooanulp of teh s.ytdu iscr(aneed oresipicn = reeancsdi catlsitisat .eopr)w reTofereh, na eerncias in ianpupoolt fo a iedabs ropug iwth dale to rucacyanic thiw hghi c.psroeiin

forerofore  to add up, the urologist himself doesn't add or remove accuracy (since this is a blood test), what decreases the accuracy is the fact that in order to be sent to a urologist you probably are sick in the first place (selection bias), so your urea nitrogen is likely to be altered. +21
sharpscontainer  I thought of precision as more of a function of variance. Variance will decrease with a greater sample size. Had a hard time because I was thinking about those 4 darn targets (wouldn't 500 darts look more spread out than 10? but no, the variance will be better) that have been in my textbooks since 7th grade and for the first time I was asked a question about this concept only to discover that I didn't have it down as well as I assumed. +1
peridot  @sharpscontainer I feel you, I thought the exact same thing. Looked into it a bit and I think it has something to do with the way standard error or standard deviation or something like that is calculated, but I'm still confused and too tired to dig further. Also, wanted to mention that this NBME has a similar question but instead it's about the 95% confidence interval - maybe that'll help you understand the precision thing better since the 95% confidence interval narrows with a larger sample size? So it's kinda tied to precision? +




Subcomments ...

submitted by step_prep3(10),
  • Pain in the hips/thighs that is exacerbated by walking and improves with leaning forward with normal posterior tibial pulses, most consistent with pseudoclaudication due to spinal stenosis
  • Claudication:Β Patient will have risk factors for peripheral vascular disease (diabetes, HTN, smoking, etc.), reduced lower extremity pulses, reduced lower extremity temperature, pain classically in the calves, reduced hair on legs
  • Pseudo-claudication (spinal stenosis):Β Positional (improves with flexion), classically affects buttocks and thighs, may be associated with back pain

https://step-prep.org/tutoring/

seagull  Cannot a herniated lumbar disk lead to spinal stenosis? asking for a friend. +  


submitted by step_prep4(4),
  • Unable to access audio, but patient has classic symptoms of a URI (fever, cough, rhinorrhea) and likely normal heart sounds (or a soft systolic ejection murmur)

https://step-prep.org/tutoring/

seagull  I also could not access the audio. I expect my refund in the mail since my assessment is compromised. ThAnKs NbMe +1  
kingfriday  I got to the audio, it was just physiologic splitting of heart sounds with breathing (inspiration). Made no impact to the answer. +  


submitted by step_prep3(10),
  • Newborn with cyanosis found to have a heart murmur and hypoxia unresponsive to supplemental oxygen, which is consistent with a severe intracardiac shunt)
  • Patient should be treated with alprostadil (or another prostaglandin analog) in order to keep the PDA open until the heart defect can be operatively managed

https://step-prep.org/tutoring/

seagull  Doesn't it take like 2-7 days for the duct to close? Why is this hour old newborn already cyanotic? +  
kingfriday  early cyanosis might be consistent with transposition of the great vessels and those can be associated with ejection murmurs and a loud S2 +1  


submitted by step_prep3(10),
  • Patient with Cushing’s triad (bradycardia, hypertension and irregular respirations) which is a sign of elevated intracranial pressure with a CT scan showing a high-density peri-ventricular hemorrhage, most consistent with a hypertensive bleed
  • Key idea: Common causes of brain bleeds include trauma, hypertension and cerebral amyloid angiography

https://step-prep.org/tutoring/

seagull  Bathrooms are very common areas of falling for the elderly/everyone. However, those tend to result in intracranial hematomas. This is a very significant brain bleed. HTN is classically associated with lacunar infarcts which honestly are not as massive as shown. THis might be a ruptured berry aneurysm from HTN but we couldn't know for sure. Not a great question but he has pre-existing HTN so I guess we'll go with it. +2  
saffronshawty  bruh, i straight up thought that was a tumor lol +  


submitted by seagull(1443),

Am I the only one always see conversion disorder of UWORLD as reassure and follow-up. This test is giving me conversion disorder.

seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +  
seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +  
bobson150  Gotta get a formal assessment before you treat I guess +2  


submitted by seagull(1443),

Am I the only one always see conversion disorder of UWORLD as reassure and follow-up. This test is giving me conversion disorder.

seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +  
seagull  I looked it up in UWORLD. THey say treatment is "Education, CBT, and Physical THerapy". +  
bobson150  Gotta get a formal assessment before you treat I guess +2  


submitted by step_prep2(17),
  • Middle-aged man with severe symptomatic hypertension with left abdominal bruit, most concerning for renal artery stenosis
  • Most common causes of renal artery stenosis include atherosclerosis, fibromuscular dysplasia and polyarteritis nodosa
  • Gold standard for renal artery stenosis is invasive angiography, whereas screening typically done with duplex ultrasound

https://step-prep.org/tutoring/

seagull  This test likes renovascular HTN for some reason. This is like the 3rd or 4 question about it. +1  


submitted by step_prep2(17),
  • Young man who presents with inflammatory back pain (worse in the morning but improves over course of the day) who has limited range of motion of the back (consistent with β€œbamboo spine” physiology), all of which is most consistent with ankylosing spondylitis that can be diagnosed with x-ray or MRI of the sacroiliac joints
  • Key idea: Indications for x-ray in setting of low back pain is (1) Osteoporosis or compression fracture (2) Suspected malignancy (3) Ankylosing spondylitis
  • Key idea: Indications for MRI in setting of low back pain is (1) Sensory/motor deficits (2) Cauda equina syndrome (3) Suspected epidural abscess or infection

https://step-prep.org/tutoring/

seagull  THe question said initial step. I thought this was a clinical dx that required elevated ESR, CRP. In reality we would order these and have him get an x-ray. I'm not sure if we can reliably dx Ankylosing Spondylitis unless we have the ESR unless the x-ray clearly shows that bones are fusing. THis is a younger guy too. +  
kingfriday  There was a uworld question that mirrors this if you use the search function you can probably find it. The reasoning they had there said that acute phase markers are usually elevated in AS but they have low specificity for establishing the dx. BONE SCAN - not good for AS, but it is good for osteomyelitis, suspected fractures, and neoplasms > MRI indicated for neurological s/sx +  
spiroskeet  Just found that UWorld question – it asked which would be most likely to establish a diagnosis in the patient. In that case, X-ray of SI joints is the right answer. However, the NBME question asked for initial step. My first step would probably be to order an ESR. It's nonspecific, but ESR is pretty much always nonspecific, so why would you ever order it? +  


submitted by step_prep2(17),
  • Infant with sickle cell disease presenting with sepsis (fever, clear rhinorrhea, lymphocytosis), which is most likely caused by Strep pneumo and can be effectively treated with ceftriaxone
  • Key idea: Sickle cell disease leads to functional asplenia, which leads to increased risk of encapsulated infections (SHiN: Strep pneumo, Haemophilus influenzae, Neisseria meningitidus)
  • Key idea: Although daily penicillin prophylaxis decreases the risk of Strep Pneumo infection, it does not completely eliminate the risk

https://step-prep.org/tutoring/

seagull  I would make a different argument. Because the infant is covered by Penicillin the pneumonia is likely gram negative. We don't have imaging to see the lung parenchyma but I would like to cover pseudomonas (ceftriaxone has partial coverage). Lastly, Ciprofloxacin given orally isn't likely to be done for inaptient (it would need to be an IV medication here). Also Cipro isn't a respiratory floroquinolone unlike moxifloxacin, gemifloxacin and levofloxacin. +1  
spiroskeet  Also, fluoroquinolones are contraindicated in children (tendinopathy) +  


submitted by step_prep(48),
  • Young woman with recent total abdominal hysterectomy who is anuric with drain creatinine = serum creatinine, AKI and mild bilateral hydronephrosis consistent with ureteral ligation/damage due to surgery
  • Key idea: Drain fluid creatinine: Serum creatinine ratio > 1 consistent with urine leak
  • Key idea: Hysterectomy and other female GU operations are highly associated with ureteral damage (especially in NBME exams)

https://step-prep.org

seagull  Why does she still have hydronephrosis bilaterally? Why doesn't the drain collect more urine if it's ligation (draining urine into the peritoneum)? Why would both be injured - WTF is this blind surgeon doing? +2  


submitted by step_prep(48),
  • Key idea: History of heel pain that is worst with first steps in morning and pain with passive dorsiflexion of toes is classic for plantar fasciitis; plantar fasciitis also commonly associated with bone spur on plantar surface of foot
  • Differential for heel pain: (1) Plantar fasciitis (2) Bone infection or metastasis (constant pain that is worst at night) (3) Calcaneal stress fracture (worse with activity and palpation) (4) Tarsal tunnel syndrome (percussion tenderness and paresthesias over posterior tibial nerve in tarsal tunnel) (5) Achilles tendinopathy (pain/tenderness at posterior heel with palpable thickening of tendon that can be reproduced with foot dorsiflexion)

https://step-prep.org

seagull  I like this ddx explanation. well done +  


submitted by step_prep(48),
  • Pregnant woman with no prenatal care presents with painless vaginal bleeding and a friable ulcer on the cervix, concerning for cervical cancer
  • Key idea: For the NBME exam, if a patient has no prenatal care, then they want you to assume that the patient does not consistently engage in care and likely does not get regular pap smears
  • Note: Fundal placenta excludes placenta previa as a cause (important cause to consider in setting of painless 3rd trimester vaginal bleeding)

https://step-prep.org

seagull  When I hear ulcer on the cervix while pregnant. I dont go jumping and claiming cancer. I think more was needed to clarify this question (as I say about all questions I miss - fml). Maybe a hx of abnormal pap smear or non hpv vaccine hx, something else. +1  


submitted by step_prep(48),
  • Patient with recent antibiotic usage develops severe diarrhea and abdominal pain, which is most consistent with C. difficile infection
  • Key idea: C. difficile leads to diarrhea by producing two main toxins that lead to enterocyte damage
  • Key idea: Toxic megacolon can be seen secondary to C. difficile infection and ulcerative colitis (at least for NBME purposes)

https://step-prep.org/

seagull  I choose sterilization because C-diff is essentially an imbalance of colonic flora due to antibiotic "sterilization" leading to expansion of C. Diff. However, I ca see how toxin- mediated is the true mechanism but the question seems dirty to me. +1  
jd1  I think also technically sterilization refers to inactivating spores (as opposed to disinfection which would not), so would imply Cdiff would be killed off too +1  


submitted by yotsubato(979),

The indications for blood transfusion for pelvic fracture patients are systolic blood pressure of <90 mmHg, heart frequency >130 bpm and clinical symptoms of shock. In an emergency, combined transfusion of red blood cells, plasma and platelets (6-4-1) is preferred (19).

So...... This question is bullshit?

study_dude_guy  I spent way too long trying to find this paper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394148/ The flow chart is the first figure In major trauma, you give 1-2 L of fluid and check for response, if they are still hypotensive you give blood products. +  
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +  
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +  


submitted by yotsubato(979),

The indications for blood transfusion for pelvic fracture patients are systolic blood pressure of <90 mmHg, heart frequency >130 bpm and clinical symptoms of shock. In an emergency, combined transfusion of red blood cells, plasma and platelets (6-4-1) is preferred (19).

So...... This question is bullshit?

study_dude_guy  I spent way too long trying to find this paper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394148/ The flow chart is the first figure In major trauma, you give 1-2 L of fluid and check for response, if they are still hypotensive you give blood products. +  
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +  
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +  


submitted by thajoker(7),

Severe, acute illness: e.g., infection with fever > 38.5Β°C (> 101.3Β°F) is a contraindication for immunizations. Although this pt has a mild illness, her temp remains at 100F

seagull  Yes, I will also add clear allergy to a vaccination (anaphylaxsis). However, seizures are not a contraindication. +1  


submitted by seagull(1443),

If you're ever unsure and it seems like it's not cancer. You slam the "Reassure" answer choice with passion.

seagull  A subconjunctival hemorrhage occurs when a tiny blood vessel breaks just underneath the clear surface of your eye (conjunctiva). The conjunctiva can't absorb blood very quickly, so the blood gets trapped. You may not even realize you have a subconjunctival hemorrhage until you look in the mirror and notice the white part of your eye is bright red. A subconjunctival hemorrhage often occurs without any obvious harm to your eye. Even a strong sneeze or cough can cause a blood vessel to break in the eye. You don't need to treat it. Your symptoms may worry you. But a subconjunctival hemorrhage is usually a harmless condition that disappears within two weeks or so. +1  


submitted by yotsubato(979),

Lactose Intolerant I guess? Not Celiac. Kind of a bullshit question.

study_dude_guy  Had the same reaction as you and then I learned that AA is a buzz word for lactose intolerance "African American and Asian ethnicities see a 75% - 95% lactose intolerance rate, while northern Europeans have a lower rate at 18% - 26% lactose intolerance" +  
seagull  I also choose Celiac's. "BuT RaCe AnD mEdICiNe DoN't Go ToGeThEr". +1  
hayayah  I think a key part to differentiate between celiac's and lactose intolerance in this question isn't race, it's because of the part that says "he occasionally had diarrhea after meals since 12 years old and then it got worse since starting college". If he had celiac's he'd have GI symptoms (i.e. diarrhea) any time he ate something containing gluten (which would be every single time he had a meal) since he was 12. You'd also see signs of fat or vitamin malabsorption in celiac's patients and other autoimmune symptoms. Whereas in lactose intolerance, it's much more likely he'd once in a while eat a lot of dairy and have his symptoms triggered, and then he starts college and has even less of a well rounded diet and so his symptoms get worse. +2  


this question would be a lot easier if the answer choice was worded "spinal epidural hematoma"

seagull  Yes! I chose dural lacerations. I quickly wrote off epidural hematoma since we usually think of it as head trauma. However, as history has shown. These authors are ass. +  


submitted by seagull(1443),

I love these shit pictures. It's like some old angry dude opened a text book from the 1950s and took a picture with his razor phone then uploaded the picture using windows 99.

seagull  Also, I think pseudomonas would present with hemoptysis and a much worse clinical picture. +  
drmohandes  Community-acquired pneumonia. If it was a CF patient = pseudomonas. In a 25-year smoker (COPD?) = H. influenzae. +  


why not myastehnia for this one? They put some LE weakness in the stem as well so that before respiratory depression made me skeptical of it being a pure descending paralysis and I went with MG instead .

study_dude_guy  I think the history just points more towards Botulism or GBS. Tbh I'm not even entirely sure why this was Botulism and not GBS +  
seagull  The nausea, vomiting, and diarrhea are also good cues that this is a foodborne illness. Then the DTR are mildly dulled which won't happen in myasthenia gravis +  
derpymd  The confusion for me is the timeline. She consumed the food 32 hours prior and symptoms started at around 24 hours. I figured with preformed toxins, the timeline would be more similar to Staph aureus (i.e. just a few hours). The learning point for me here was that it can take 12-72 hours for symptoms to occur depending on dose. +  


my reasoning:

  • diuretics cause hypokalemia β†’
  • hypokalemia causes ↑ digoxin binding to Na/K ATPase β†’ cardiac dysfunction (i.e. PVCs)
seagull  They don't specify the exact diuretic. More cause hyperkalemia than not. Also, digoxin causes hyperkalemia (mild). This questions answer is infact opposite to what is a logical conclusion. +2  


submitted by yotsubato(979),

This one made no sense. Celecoxib is already the strongest NSAID. I would rather give Dexamethasone. Which works along a seperate mechanism of action.

jaypat  Indomethacin is typically the first choice NSAID for acute gout flares. Then glucocorticoids. Lastly Colchicine +  
seagull  I also choose steroids since they were on a NSAID. fml +  
creamy  Naw dawg. Celecoxib has anti-inflammatory efficacy hence the categorization as a NSAID. In fact, gout patients treated with Celecoxib have the same treatment response as Indomethacin. Celecoxib is actually listed as an alternative to nonselective NSAIDs for acute gouty flares. This was just a bumbass question. +1  


submitted by jesusisking(16),

Did anyone else think autonomic insufficiency given the diabetes? I know it was previously well controlled but still a 10 year history

seagull  ya dude. +  


submitted by step_prep4(4),
  • Young girl with a history of chronic corticosteroid use and cushingoid appearance who presents with constant back pain with vertebral point tenderness with imaging showing vertebrae with increased lucency, most consistent with a compression fracture in the setting of steroid-induced osteoporosis
  • Key idea:Β Vertebral compression fracture comes in 2 flavorsΒ (1) Chronic fracture:Β Painless with progressive kyphosis and loss of statureΒ (2) Acute fracture:Β Low back pain with decreased spinal mobility + tenderness at affected level
  • Key idea: Causes of point tenderness over vertebral body includes compression vertebral fractures, osteomyelitis and metastatic disease to vertebral bone
  • Risk factors for osteoporosis –> compression fracture: Low weight (osteoporosis), increased age, women, chronic corticosteroid use or Cushing syndrome

https://step-prep.org/tutoring/

seagull  Jesus dude, just take my virginity while you're at it/ +3  


submitted by seagull(1443),
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eTh ncsmeiats fo hsit unoiestq emda me movit b.dolo

nOe ady a ittenap llwi lkoo em in eht eyse dan ,ksa e"Whre ear tdetspeiri bernko n?"dwo I illw lmise ta temh dan sya, he"t itetainsnl ascuom nad tno the mo.u"duned lyehTl' eimsl cabk adn l'Il wkal ywaa dan hnitk fo sthi momnet as I umpj mfor hte wndoiw.

sympathetikey  Too real. +3  
mcl  how do i upvote multiple times +16  
trichotillomaniac  I made an account solely so I could upvote this. +30  
dragon3  ty for the chuckle +6  
cinnapie  @trichotillomaniac Same +3  
thedeadly96  XD made my day! +  
hardly43  RIP legend @seagull +  
seagull  A legend never die +1  


submitted by medstudied(1),
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Cna msoneeo axpinel yhw eht rreocct raeswn ofr eth ntouseqi ehre si nuooijngtca tbu an’ct eb isan?ottpinrso

catacholamine16  Transposition is when a segment of DNA (in this case, coding for resistance) jumps onto a plasmid within the same bacterial cell. That plasmid might then transfer to another nearby bacterial cell via conjugation. Transposition is happening WITHIN the bacterium. Conjugation is how that resistance gene gets transferred. +12  
lsmarshall  Also, E. coli is the classic example of a bug tat uses conjugation. ^but explanation above is correct^ +2  
seagull  I think he might have did what I did. I got Transformation mixed up with transposition. FML +3  
luciana  I still can't understand why it can't be transduction. Is it just because of bacterial types? +  
thotcandy  @luciana Yes, I believe so. You have to remember which bacteria have a conjugation pilus - E. coli is the most popular one because of its F sex factor (remember the F+ x F0 thing in FA?) +  
mgemge  I was also confused why it's not transduction...but simply as a crappy memory pneumonic TranNsduction TraNSfers ToxiNs FA 2020 p130 +  


submitted by seagull(1443),
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ypitoiIcd neams --- ybtdoina igsanat dyin.atbo B lelcs tond' ehva srcfaue ebdniaoits btu emre issneytzeh .mthe

hungrybox  This is wrong. PLASMA cells (mature B cells, the ones found in multiple myeloma) secrete antibodies, but IMMATURE B cells have antibodies that haven't switched classes yet (IgM and IgD). +5  
hungrybox  To clarify - immature B cells have antibodies attached to their membrane. +  
seagull  I should have clarified that I was speaking about mature B cells. Thank You +3  
sahusema  So because MM has mature B cells, exogenous antibodies can't attach to them. Am I getting that right? +  
cienfuegos  What is an Anti-Idiotypic Antibody? As shown in figure 1, an anti-idiotypic (Anti-ID) antibody binds to the idiotype of another antibody, usually an antibody drug. An idiotype can be defined as the specific combination of idiotopes present within an antibodies complement determining regions (CDRs). A single idiotope, is a specific region within an antibodies Fv region which binds to the paratope (antigenic epitope binding site) of a different antibody. Therefore, and idiotope can be considered almost synonymous with an antigenic determinant of an antibody. https://www.genscript.com/antibody-news/what-is-an-anti-Idiotypic-antibody.html +1  
cienfuegos  @sahusema: almost exactly correct, but it's important to note they are talking about idiotypic antibodies specifically because by definition these bind the "idiotype" of another antibody (see definition above) +  


submitted by sattanki(69),
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tAylppearn tereh si a eclopmyelt esaptear slnpai drco fxerel wehre dtecir enlepi titismanulo dlsae to na orenitce. iTsh elxefr olyn sdene an tacitn rac in S4-S2, os as nlgo sa tihs ngoier is tno r,jidneu an eneoicrt anc lsilt uc.rco ,eewHrvo hwit erncitonats at ,8C nteh eht ccieyshnpog rtneiceo ferxle ncoatn c,cruo sa siht urqieser iencdesndg riefsb fmro het eortxc.

lsmarshall  Just saw a good summary of nerves/vessels involved saying, "pelvic parasympathetic fibers from S2-S4 can cause cavernous arteriole vasodilation via the cavernous nerve without of central stimulation." +7  
seagull  S2-3-4 keeps the penis off the floor +36  
drdoom  Modifying @seagull into iambic pentameter: β€œS2, S3, and Number 4 / keeps the big ole penis / off the floor” +1  
myoclonictonicbionic  I can assure you the validity of answer (speaking from experience) +2  
raddad  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896089/ Under the "autonomic control" header +1  
llamastep1  I've always wondered how quadraplegics got it up. I guess their girls help em lol +  


submitted by lsmarshall(396),
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eaUr ycelC rsdsDeoir ;tg& dolaesIt esreev hyaronaimpmeme (;gt& 001;0 .e,.i on orteh vrseee lamitbeco rsnbcdtesaui

hinOeritn satcaebnasyamrlr efecdiyinc t&;g smto( mocnom reua clyce d.)is tircoo ardcmaauiaiiei/cd, ehmrniyamoepam

Oiracgn icmAieads > eproma,imyanmeH aagnnip-o doasisic, koitses morf( l)iyhoymaegcp

unehia-Mmcdi alo-AcyC sddaoenyehgre iieeyfccnd &g;t ,oemyiaarmpenHm eyhiotptcok hiocymeglpya ees(n ni otnxΞ²od-iai rrsesdodi, XCTPEE sodlhuyokoapetydn)rre

rLiev yiftnoscund &tg; amiyneH,pmeorma sFTL semdes ,up rdeol .tp

lsmarshall  Summary of metabolic issues relating to hyperammonemia +7  
seagull  i'm leaning towards Ornithine transcarbamylase deficiency. +3  
notadoctor  Not sure why this isn't considered a mitochondrial disorder since the issue is Ornithine transcarbamylase deficiency in the mitochondria? +2  
charcot_bouchard  if it was mitochondrial disorder no one would escape +3  
wowo  figure in OTC deficiency, they might have to explicitly mention the orotic aciduria AND typically presents earlier, around 24-48hrs of life after they've fed (at least per BB) + also per BB, propionic acidemia and MM acidemia have an onset of weeks to months and lead to build up of organic acids --> acidemia in addition to hyperammonemia (not sure why, but several aa enter the TCA cycle via propionyl CoA --> methylmalonyl CoA --> succinyl CoA, but now this is defunct d/t enzyme deficiencies...?). Anywho, propionic acidemia described on FA2019 p85, but doesn't list hyperammonemia +2  
artist90  i think it cannot be Ornithine transcarbamylase deficiency bc it is XR disease. this pt has a healthy 2yr old brother which rules out X-linked recessive disease correct me if i m wrong +4  
artist90  it is 100% Propionic acidemia Uworld Q-id: 1340. it is an exact copy question of uworld. i got it wrong bc i forgot these are organic acids. But i am still confused on 2 things 1-how does acidosis cause Hypoglycemia and Ketosis. 2-why is Ammonia elevated in these pts bc urea cycle will be fine? +  
yb_26  1) hyperammonemia is seen in all urea cycle disorders except arginase deficiency 2) organic acids directly inhibit urea cycle => hyperammonemia (from UWorld) +1  
yex  According to UW, there is another question # 1341. This one refers to methylmalonic acidemia (ORGANIC ACIDEMIA). HYPOGLYCEMIA results from overall increased metabolic rate leading to increased glucose utilization and direct toxic (-) of gluconeogenesis by organic acids. The presence of hypoglycemia leads to increased free fatty acid metabolism that produces KETONES, resulting in a further anion gap met acidocis. Finally, organic acids also directly (-) the urea cycle, leading to HYPERAMMONEMIA. +10  


submitted by colonelred_(99),
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ehT dssiionag is aerstyrrbw ahnieomagm, nlcymmoo nhsappe ni sd,ik nofte rlseveso on sti own sa yhte gte e.odrl

shaeking  A strawberry hemangioma is normally pink or red (which is why it is named strawberry). The description has a flat purplish lesion which makes me think of a port wine stain on the face. How do you know to think of strawberry hemangioma over port wine based on this question stem? +3  
seagull  the age is key here. Newborns have strawberry hemangiomas typically on their face. Sturge-Weber could also be the case but none of the answer choices matched to that description. +1  
vshummy  I would agree with Sturg Webber nevus flammeus but I also noticed First Aid says it's a non-neoplastic birth mark so I should have known not to pick malignant degeneration or local invasion. Also because capillary hemangiomas don't have to be flat but the nevus flammeus is consistently flat. But I'm also reading on Wiki that the nevus flammeus doesn't regress so they must be trying to describe strawberry hemangioma even though I don't agree with their color choice... +  
nala_ula  Maybe (and I can only hope I'm right and the test makers are not -that much of- sadists) they would have made sure to write "in a cranial nerve 5 (either ophthalmic or maxillary) distribution" if it were Sturge-Weber. +1  
j44n  this is literally on every NBME along with the 10,000 ways to not get a boner +  


submitted by brethren_md(88),
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Sidtpu einsotu,q yonlesth sutj akte ryou etbs sesug and omev on .oll

seagull  β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–ˆβ–€β–€β–‘β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘ β–‘β–‘β–‘β–‘β–‘β–‘β–„β–€β–€β–€β–€β–‘β–‘β–‘β–‘β–‘β–ˆβ–„β–„β–‘β–‘β–‘β–‘ β–‘β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–β–‘β–‘β–‘ ░░░░░░▐▐░░░░░░░░░▄░▐░░░ β–‘β–‘β–‘β–‘β–‘β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–„β–€β–€β–‘β–β–‘β–‘β–‘ ░░░░▄▀░░░░░░░░▐░▄▄▀░░░░ β–‘β–‘β–„β–€β–‘β–‘β–‘β–β–‘β–‘β–‘β–‘β–‘β–ˆβ–„β–€β–‘β–β–‘β–‘β–‘β–‘β–‘ β–‘β–‘β–ˆβ–‘β–‘β–‘β–β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–„β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘ β–‘β–‘β–‘β–ˆβ–„β–‘β–‘β–€β–„β–‘β–‘β–‘β–‘β–„β–€β–β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘ β–‘β–‘β–‘β–ˆβ–β–€β–€β–€β–‘β–€β–€β–€β–€β–‘β–‘β–β–‘β–ˆβ–‘β–‘β–‘β–‘β–‘ β–‘β–‘β–β–ˆβ–β–„β–‘β–‘β–€β–‘β–‘β–‘β–‘β–‘β–‘β–β–‘β–ˆβ–„β–„β–‘β–‘β–‘ ░░░▀▀▄░░░░░░░░▄▐▄▄▄▀░░░ THis Question β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘β–‘ +2  


submitted by brethren_md(88),
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siuqreeR nwnikog ohw to eauclltac an nnaoi gpa - kolo it up. nI hsit c,aes it si a mrolna nonai agp baimoctle aoicsid.s Kwon eht imsnncemou SUILMDPE adn .SHRASAD alnRe lrTbuau soisdcai si eth lnyo arwsen eoihcc tath si an pelxaem fo a amnolr inona bmaoltcie sisa.dcoi

mousie  Anion Gap: Na - (Cl + HCO3) = normally around 10-12 +2  
seagull  good to know. I keep looking up the urine values but all it said was "varies", then I threw my computer and yelled "does that vary Mother F****ers. I do feel better now. +59  
_yeetmasterflex  glad I wasn't the only one who got very pissed off at the urine values +4  
fulminant_life  Usually the first thing I look at is whether or not the Cl- is high. Generally if the Cl- is high its going to be a normal gap +7  
henoch schonlein  i think they gave you the urine values bc you can calculate the URINE anion gap which is (Na + K - Cl). In this case the Urine Anion Gap is positive (5). Boards and Beyond mentions that a positive UAG is due to Renal Tubular Acidosis Type 1 (inability of alpha intercalated cells to secrete hydrogen ions). just another approach to answer this q +17  
270onstep1  Actually diarrhea is the "D" in "HARDASS"(reason why I was stuck between Chron's and RTA). Ended up getting it right with RTA.. +1  
talha_s  So the reason this is not Crohn's disease is actually what BnB explains in Renal Tubular acidosis video. Anytime there is a Metabolic Acidosis with intact kidney secretion of H+, the URINARY Anion gap (Na+K-Cl) is NEGATIVE. This is because the excess NH4 that is secreted into urine is combined with Cl-. Therefore, in Crohn's disease and Type 2 Renal Tubular Acidosis, the urinary anion gap is NEGATIVE. In this question, the urinary anion gap is POSITIVE so this would be an example of Type 1 RTA because the kidney can not excrete H+. I got it right by chance, definitely did not understand it in this much detail when I was answering it lol +7  


submitted by drdoom(819),
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fetAr eth ffcu si eidt, eth clesl dna tuesis dailts ot het fcfu iwll ocnniuet sgnnuoicm PAT (TPP&Atg;-AD), utb no hefrs oobld will eb iedrelvde to β€œcar”le twah lilw be an icgucaalumnt tmouna of DAP nda oehtr btaoimtse.el PDA sne=A)ne(iod is sfetil a yrxpo fo ntmcuisonpo adn visedr taislidooavn fo ai!eertrs vEotuilo(n is !arm)ts inescngarI Aonne/isAdDPe ni a calβ€œlo einevmn”ontr si a ilngsa ot the bdoy that a tol fo tiomuspocnn is nrccurigo reh;et uht,s rtraiese dan iersotlrae narytllua tedial to naseecir lbood wfol sreat dna eeβ€œpsw ayw”a iltbeomca tc.oydurbsp

lispectedwumbologist  You're a good man. Thank you. +  
drdoom  So glad it helped! +1  
seagull  very well put, thank you +1  
eosinophil_council  Great! +  
aisel1787  gold. thank you! +  
pediculushumanus  beautiful explanation! +2  
rockodude  this explanation was on par with Dr. Sattar IMO +1  


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nCa nodabyy iaelnpx tihs n?eo I upt detaerpe tesst ecaebus I adsmues an 8-rldeo3-ya noamw is na sluauun hpgdmoreiac rfo sihi.spyl

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. +10  
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 β‰  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 seagull(1443),
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I hhtgtuo isth wsa a tyep 1 TRA but I saw ro.ngw nyA nsesuit?gosg

seagull  It looks like it was a type II RTA. The difference is incredibly subtle from the info given in this question. +13  
gonyyong  He has Fanconi syndrome which is generalized reabsorption defect in PCT which leads to metabolic acidosis and hypophosphatemia β†’ can lead to rickets Also, does lead to type II RTA +15  
duat98  Also the proximal tubule is the place with the highest phosphate absorption rate. That's why PTH works here mostly and a little bit in the distal tubule. +5  
boostcap23  Another easy way to go about this one is the question tells you he has metabolic acidosis, the only that can happen with is Fanconi/Type2 RTA. The rest will cause hypokalemia and metabolic ALKALOSIS. (pg 586 FA) Personally thought if they were going for Fanconi syndrome they would describe a lot more symptoms for the kid like growth failure or hypophosphatemic rickets but its NBME so. +1  


submitted by karljeon(112),
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I don't owkn fi eterh si an eontuaqi orf s,ith btu I aclasybil ueppmd uot reyev nivisdoi sosrca the tebal to egt %5~ on gaave.er

erHe tehy r04:ae0 / 60,00 = 0.760 025 / ,5060 = 500030.4 / 05,35 = 0.305060 / 005,5 = 0.02 9550 / ,0084 = 200.5

heT veeagar fo these %s fro lal eht ayres = o%5 .S.58 t'tsah lceos oungeh ot .5%

seagull  good work. I found this question annoying and gave up doing those considering the amount of time we are given. +4  
vshummy  Well just don’t include the intake year... because that messed me up.. +13  
_yeetmasterflex  How would we have known not to include the intake year? From average **annual** incidence? +  
lamhtu  Do not include intake year because the question stem is asking average annual incidence. The 4000 positives at intake could have acquired HIV whenever, not just in the last year. +7  
neels11  literally didn't think there was an actual way to figure this out. but my thought process was: okay incidence means NEW cases. so the annual average at the end of 5 years would be: (# of NEW people that tested positive at the end of year 5) / (# of people at that were at risk at the beginning of year 5) <--- aka at the end of year 4 250/5050 = 4.95% also if you look at year 5: you'll see that the at risk population is 4800 when 300 new cases were found the year before. 5050 at the end of year 4 MINUS the 300 new cases at the end of year 4 should give you 4750 as the new population at risk. but notice that end of year 5 we have 4800. idk if that means 50 people were false positives before or 50 people were added but in incidence births/death/etc don't matter it's kind of like UWORLD ID 1270. assuming average annual incidence is the same as cumulative incidence this was just a bunch of word vomit. sorry if it was unbearable to follow +  


submitted by seagull(1443),
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acwkm.i._/sweyiiidMemal_Fo/mgsieio:ljoedtdd:ripphme#ail.tesatB/c/tis/stnr/geitopsSGiasyBk

I blveeie tish si acyltlua siatddnimese mysBtolecsa ude to teh "raBod Bdeas d"dgBiun as esen in teh ipu.cter

seagull  However, given the stain and some of the features I now see that this is most likely Crypto. THey like similar. my bad +15  
mjmejora  oh what a catch! I also thought this was Blasto until you explained otherwise +  
drmohandes  Blasto = broad-based budding, the two 'circles' look equal in size. Crypto = narrow-based -unequal- budding. +6  
paperbackwriter  ^ I would disagree a little bit. "Broad based" and "narrow based" refer to how smushed the circles are. So narrow based is when the membrane bit they're sharing is small, and broad based is when they share a lot of membrane. So if just pinching off --> crypto, if they look stuck/have a flat membrane between them --> blasto +1  


submitted by mousie(211),
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sI 54 tsinuem oot lgon to be chlatyapnica dna woldu teh easebnc fo rhas iaca,tr(riu rptusiru) RO ?ccanylipatha

hayayah  Yes! Allergic/anaphylactic blood transfusion reaction is within minutes to 2-3 hours. (pg 114 of the 2019 FA has a list of them ordered by time) +7  
hayayah  (also allergy / anaphylactic presents with more skin findings (urticaria, pruritus) +6  
seagull  The time through me off too. I though ABO mismatch since it occured around an hour. I thought TRALI would take a little longer. +7  
charcot_bouchard  Guys anaphylactic reaction to whole blood doesnt occur much except for selective IgA defi. so look out for prev history of mucosal infection. And it can have all feature of type 1 HS inclding bronchospasm. +5  
soph  I saw hypotension and though anaphylaxis........ -.- +  
usmile1  Chest Xray showed "bilateral diffuse airspace disease". This is much more indicative of TRALI than anaphylaxis which would have wheezing and possibly respiratory arrest but no actual damage to the lungs. Additionally there was no urticaria or pruritus one would expect to see with anaphylaxis. +5  


submitted by lsmarshall(396),
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lsnarPe"arat evhae )tli(f cucros ndguir rithg vrcnalruiet tyrehrophyp e.i.( egemnatnelr) or vrye yrrela evrese eflt rlaati ee"rn.gmtlean VR hotrrpyepyh nca eb snee os aiesyl sueaceb the VR si ta eth troierna cfresau of eht .tcshe

nI itsh natitep dolob fmor AL to VL rdeeacess ni tat,snauoir os ti is oging hwrsm.eeoe ormF teh 2O a.ts we nac cdudee tehre is aobylbrp a DSV c(serneaid VR eussrerp ldwou caues HRV and nraspatreal veahe). rt,hFrruemo het tingteev si lylkie ngrebcsiid gotrlyate of laltof saeudc( yb oruitarenpesro inaleecmdpts fo teh lrubiianfdnu t)mpus.e In Tte ,ssplle RV ofoutlw si too tsceboutrd nda tpteani tges cosinasy dan Lt;R&g tshningu utsSqa arseneic SVR, ienredscag tgL;R& hsgtiun,n giuttpn rome doolb hgouhrt amnlruyop urcciit dna ievlgnrie syaioc.sn

seagull  i'm pretty sure your a prof and not a student. +15  
nor16  nevertheless, we are greatful for explanation! +  
niboonsh  I remember seeing a question describe parasternal lift in the context of pulm htn. still got this wrong tho fml +  
anotherstudent  Did my question have a typo? It says O2 saturation in the right ventricle is 70, which is equal to the Right atrium and vena cava. It says the O2 saturation in the left ventricle is 82%, which is a decrease from the LA (95) but not equal to the RV, which is why I thought there wasn't a VSD, I assumed there was a weird shunt from the LV to some other part. Will O2 saturation not always equalize? +1  
pseudomonalisa  This is a right to left VSD due to the pulmonic stenosis present in Tetralogy of Fallot. O2 sat will be low (70) in the right ventricle, and from there it'll enter the left ventricle and mix with freshly oxygenated blood coming from the left atrium (95). Because of the mixing, the O2 sat of blood in the left ventricle will be somewhere in the middle of 70 and 95 (82 in this case). You're correct, though, that most other VSDs are left to right and you'd see greater O2 sat in the right ventricle in that case (not sure if it equalizes with the left ventricle though). +  


submitted by mousie(211),
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si ihts ucbaseut adiesdcrtion ossidatcae eofarinmvMolarpribtee- ?GN

jus2234  The question describes how he had a strep infection 15 days ago, and now this is poststreptococcal glomeruloneprhitis, which can also be described as proliferative glomerulonephritis +10  
seagull  The question would be too fair if it just said PSGN. Instead we need to smell our own farts first. +65  
yotsubato  And they used terminology NOT found in FA +5  
water  who said they were limited to FA? +2  
nbmehelp  FA uses the common nomenclature and the fact most of our other resources use the same nomenclature for this, I think we can agree that is is the accepted terms. If they're gonna decide not to use the nomenclature that most medical students are taught then they should provide their own study materials at that point for us to use. The test shouldn't be this convoluted for no reason. +7  
alimd  Ok. They can use terminology whatever they want. But BUN-CR>20 is CLEARLY prerenal right? +  


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hWy ldowu ti nto be amnaie of ncoihcr edissea thiw ecedrdaes murse rieafrtrnsn onnrtntae?coic

lispectedwumbologist  Nevermind I'm stupid as fuck I see my mistake +1  
drdoom  be kind to yourself, doc! (it's a long road we're on!) +20  
step1forthewin  Hi, can someone explain the blood smear? isn't it supposed to show hypersegmented neutrophils if it was B12 deficiency? +1  
loftybirdman  I think the blood smear is showing a lone lymphocyte, which should be the same size as a normal RBC. You can see the RBCs in this smear are bigger than that ->macrocytic ->B12 deficiency +22  
seagull  maybe i'm new to the game. but isn't the answer folate deficiency and not B12? Also, i though it was anemia of chronic disease as well. +  
vshummy  Lispectedwumbologist, please explain your mistake? Lol because that seems like a respectible answer to me... +9  
gonyyong  It's a B12 deficiency Ileum is where B12 is reabsorbed, folate is jejunum The blood smear is showing enlarged RBCs Methionine synthase does this conversion, using cofactor B12 +  
uslme123  Anemia of chronic disease is a microcytic anemia -- I believe this is why they put a lymphocyte on the side -- so we could see that it was a macrocytic anemia. +2  
yotsubato  Thanks NBME, that really helped me.... +1  
keshvi  the question was relatively easy, but the picture was so misguiding i felt! i thought it looked like microcytic RBCs. I guess the key is, that they clearly mentioned distal ileum. and that is THE site for B12 absorption. +6  
sahusema  I didn't even register that was a lymphocyte. I thought I was seeing target cells so I was confused AF +  
drschmoctor  Leave it to NBME to find the palest macrocytes on the planet. +4  
zevvyt  so i guess size is more important than color cause those are hypochromatic as fuck +  


submitted by sattanki(69),
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osDe eonnay eavh nya deia on sith seinqt?uo tgThuho it saw S.LA

ankistruggles  I thought it was ALS too (and I think it still could be?) but my thought process was that a lower motor neuron lesion would be the more specific answer. +2  
sattanki  Yeah makes sense, just threw me off cause ALS is both lower and upper motor neuron problems. Corticospinal tract would have been a better answer if they described more upper motor neuron symptoms, but as you said, they only describe lower motor neuron symptoms. Thanks! +6  
mousie  Agree I thought ALS too but eliminated Peripheral nerves and LMN because I guess I thought they were the same thing ....??? Am I way off here or could someone maybe explain how they are different? Thanks! +1  
baconpies  peripheral nerves would include motor & sensory, whereas LMN would be just motor +15  
seagull  Also, a LMN damage wouldn't include both hand and LE unless it was somehow diffuse as in Guil-barre syndrome. It would likely be specific to part of a body. right??? +1  
charcot_bouchard  No. if it was a peri nerve it would be limited to a particular muscle or muscles. but since its lower motor neuron it is affecting more diffusely. Like u need to take down only few Lumbo sacral neuron to get lower extremity weakness. but if it was sciatic or CFN (peri nerve) it would be specific & symptom include Sensory. +1  
vulcania  I think it's ALS too. The correct answer choice here seems more based on specific wording: the answer choice "Corticospinal tract in the spinal cord" wouldn't explain the tongue symptoms, since tongue motor innervation doesn't involve the corticospinal tract or the spinal cord (it's corticobulbar tract). This is a situation of "BEST answer choice," not "only correct answer choice." +  


submitted by beeip(123),
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yltIiainb ot aeltvee eth paatle susgsetg dmgeaa fo eht saugv .veern

F. (CN )X

atstillisafraud  I guess F is the vagus nerve. Thanks to NBME I am also training to become a mind reader. +31  
seagull  Thanks to the NBME I have crippling depression +38  
drdoom  bonus cadaver diagram via @mcl +2  


submitted by sympathetikey(1265),
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aMd at flyems ofr ghcngina ym a.nwesr

ulyFta cgoli dmea me wndero if itghnit uryo hdae doluw aesduc edisernac IPC s,o liek a hcusing urecl, oyu oldwu etg asrdcenei gVuas revne ciyvatti dan myaeb raryadabidc + oyt.shniepon uBt I ugsse hte RSAA tesyms duowl hvae oadeutntccer htta nad cdseau stonocrniaisvtco veor 24 srhuo, os mpoveyHlcoi khcos si eindyieflt het steb chieoc.

aylAws dsuolh go ithw the usvboio nwrsae ):

seagull  I had the idea that this was a neurogenic shock and increasing intracranial pressure could affect the vagus too. I think the question really wants us to go that direction. +13  
uslme123  The Cushing reflex leads to bradycardia! +4  
purdude  Wait I'm confused. I thought hypovolemic shock leads to an increased SVR? +2  
littletreetrunk  apparently, there's a thing called sympathetic escape that can happen after a while (i.e. he's been out for 24 hours): Accumulation of tissue metabolic vasodilator substances impairs sympathetic-mediated vasoconstriction, which leads to loss of vascular tone, progressive hypotension and organ hypoperfusion. +  
littletreetrunk  also also if he hit his head he could have loss of sympathetic outflow from a hypoxic medulla which could lead to vasodilation, which further reduces arterial pressure, but this was a hard one for me lol. I also put increased ICP wah. +  
catch-22  Any lack of sympathetic outflow/increased vagal outflow should reduce HR, not increase it. Further, you would expect brainstem signs if there was hypoxia to the brainstem. For example, if you had damage to the solitary nucleus, you wouldn't be able to regulate your HR in response to reduced BP. Since this patient has reduced BP and increased HR, this indicates that the primary disturbance is likely the reduced BP. He's also been in a desert for 24+ hours so. +3  
charcot_bouchard  In a patient who develops hypotension following high-energy trauma, neurogenic shock is a diagnosis of exclusion that is made after hypovolemic and obstructive cardiogenic shock have been ruled out! Plus Absent Bradycardia rules it out +2  


submitted by wired-in(67),
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enantianceM does uflaorm si Cs(s Γ— Cl Γ— )tua Γ· F

rhewe Css si etatytedsa-s tratge aasmpl c.nco of ur,dg lC is c,nraleaec tau is aedogs avitlren apm&; F si viliaby.iiatabol

eiNhetr sadgoe rianevtl onr biltyaiviaoibal si veng,i so iggnnior ohste &;mpa plggnugi in het nerbmus ler(fcua to ocntrev ntuis ot :gadgmy)k//

( =21 /gmuL Γ— 1 0m/00g1 )gu Γ— 0.(09 r/gL/hk Γ— 1000 /m1L L Γ— 24 r/1h dy)a
= .2952 m/gdaykg/

h..hwic. itn's any of hte swearn hoeicsc ets.ild hTye must hvae uedordn 009. /hg/rLk to .01 /,r/gkhL dna dnoig os sgive xtcelya .288 k/g/dygma ihoc(ce C)

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +72  
hyoid  ^^^^^ +11  
seagull  lol..my math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but iΒ΄d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +3  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +2  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +15  
qball  Me after plugging in the right numbers and not rounding down : https://i.kym-cdn.com/entries/icons/original/000/028/539/DyqSKoaX4AATc2G.jpg +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😑 +  


submitted by mousie(211),
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anC oeenmso selepa ilnepax tshi ot ?em I tdn'o undtneards ywh rngastti teh rhote gudr wlduo ton utcon sa ilxucsneo aictrier?

seagull  This has to do with Intention-to-treat analysis. Essentially, when participants are non-adherent but the data shouldn't be lost. They just undergo another statistical model to account for their changes. Here is a nice video https://www.youtube.com/watch?v=Kps3VzbykFQ&t=7s +19  
dr.xx  Where does the question mention "intention-to-treat"? +  
notadoctor  They seem to be pretty obsessed with "intention-to-treat" it's been asked in one way or another in all the new NBMEs that I've done. (Haven't done 24 as yet) +8  
wutuwantbruv  They don't, intention-to-treat is just the best way to go about it @dr.xx +  
smc213  Great for ITT: https://www.youtube.com/watch?v=Kps3VzbykFQ +4  
yex  I agree with @notadoctor !! +  
ergogenic22  i think if it were per protocol, both groups would be excluded, the ones that were inconsistent, the ones that dropped out, and the ones that switched. But answer choices only allow ITT or exclusion of one group. +  


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Hwo is this het awrnes fi hrete is no lamify iohrtsy of cnreturre rae?sfurtc I thotguh stoneosgsiee acpfeitrem wsa amosualot tdano?nmi

seagull  Exactly!! it's an autosomal dominate disease! +10  
emcee  Autosomal dominant diseases are variably expressive. Still, I think this was a badly written question (should have given us some family history). +  
wutuwantbruv  Also, FA says that fractures may occur during the birthing process, which is what I believe they were going for. I don't believe these findings would be seen at birth with any of the other choices. +  
d_holles  Yeah I thought I outsmarted NBME by selecting Rickets bc it said no family history ... guess I got played lol. +9  
jean_young2019  Could it be a sporadic cases? Spontaneous Mutation This is a change in a gene that occurs without an obvious cause, in a family where there is no history of the particular gene mutation. OI is inherited as an autosomal dominant trait. Approximately 35% of cases have no family history and are called "sporadic" cases. In sporadic cases, OI is believed to result from a spontaneous new mutation. http://www.oif.org/site/PageServer?pagename=Glossary +6  
avocadotoast  Amboss says the severe subtypes (types II, III) of OI are usually due to a new (sporadic) mutation in COL1A1 or COL1A2, while patients with the mild forms (types I, IV) typically have a parent with the condition. +  


submitted by nlkrueger(43),
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.... dowul we reayll aekt teh rwod fo a fidern who lydtineief atnc' eb i?monrcfde I flee eikl siht is eislaimdgn

lispectedwumbologist  All the other answer choices make you come across as an asshole. Easy way to ace ethics questions is to just not be an asshole +9  
seagull  I would be a bigger asshole when the family came I'n after I pulled the plug...opps...but the friend said +29  
dr.xx  The patient has no wife, children, or close relatives... +3  
nwinkelmann  @lispectedwumbologist this is going to be my technique, because I've gotten a couple of these wrong, but I completely agree with everyone else's sentiments of suspicion of going off what a friend said without any confirmation about state of advance directives, etc. It's really dumb. +3  
paulkarr  With these questions; you have to take what NBME says at face value. If it says no family, he really does have no family. This friend is also claiming that the 78 y/o said this about himself, so we know it's the patients wishes rather than someone else's wishes for him. (A son saying he can't let go of his father yet despite the patient's DNR type of situation). +1  
suckitnbme  I think the point here isn't that we would take the patient off the ventilator because the friend said so. The answer is saying "Thank you for your input, we will take that into consideration." It's completely non-committal. +7  
vivijujubebe  they say no close relatives, which means he could have remote relatives, relatives must be asked before listening to a stranger/friend's words..... +  


submitted by welpdedelp(219),
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I hsoec hist /bc its eht tmso onmmoc geoanhpt ofr sink ocnenifits

seagull  same here +2  
sympathetikey  Some bowlsheet +11  


submitted by lfsuarez(141),
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02 fo het 001 men ttowiuh estaptor anecrc ahve laoambnr tset u.relsst

Sftiepyccii = PP+/FTNF = 00102/ = 0.8 = 08%

seagull  almost. 100/120 = 83% roughly 80% +  
amirmullick3  Not sure what lfsuarez and seagull above mean. Here is my explanation. Specificity = TN/(TN+FP). This test gave 20 false positives out of 100 people, and only 15 true negatives out of 50 men. Specificity also equals 1-FPrate, and here the FP rate seems 20% so 100%-20%=80%. +4  
yb_26  abnormal test result means pt has cancer => TP = 35, FN = 15 (50-35), FP=20, TN =80 (100-20) => specificity = TN/(TN+FP) = 80/100 = 0.8 (in % will be 80%) true negatives are 80 out of 100, not 15 out of 50 +2  
bulgaine  If you replace the values from the question in the table of page 257 of FA 2019, yb_26 explanation is correct. Abnormal test = patient has cancer = test + Question says 35/50 men with prostate cancer (so all 50 have cancer) only 35 have abnormal test results, meaning that TP=35 (disease + test +) and FN= 15 (disease + test - because they do have cancer but the test was not abnormal for them ). 20/100 men without prostate cancer have abnormal test results meaning all 100 DONT have cancer but 20 show that they have cancer when its not true so FP=20 (disease - test +) and TN =80 (disease - test -) +  


submitted by ferrero(40),
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A vyer mairsil ountiqes I hvea enes ni ansQkb ilwl ask ywh a inaptte iwth ighrt htear ilfreau esdo not pdoevle adeem adn teh sneawr si ciaesrden hcmptlyia dgr.niaae I tog iths neqsiout nogrw lirialgoyn eecasbu I aneewdsr goanl this elin of nnieorgas tbu I knthi in iths asec it lla ahs ot do wiht EREHW eth tarxe esspuerr si mnogci or.fm In htis iuetqsno hte tp sha dolciasit nieyhenrtsop so uoy nac htkin buato eth esrupers as oncgmi "a"wrdrfo os nnitctiogscr yilrpaaplecr epnsrthcsi anc etnrvep an sacreein in reuerssp in the plylacria e.db rwoHeve rfo hgirt rheat lriefua tsih aetrx udlif si mcigno from het TPPSIOOE inedctori bsdw(arcka orfm eth ghrit treh)a adn nngiscictotr plyiarlrceap rnthssicep cna od hoignnt no( ooietspp edsi fo lrylaapic ebd) - hte lnoy way to ntverpe mdeae si to ienrecas imtlhyacp ridneaag.

seagull  The question clearly lead us to think about Osmotic pressure by talking about protein and urine. I wonder how many people used that line of reasoning (like myself)? +15  
mousie  Great explanation, I chose lymphatic drainage for the same reasoning (similar Q on different bank) +6  
sympathetikey  My reasoning was much more simplistic (maybe too simple) but in my mind, systolic BP is determined by Cardiac Output and diastolic BP is determined by arterioles. Therefore, what comes before the capillary and regulates resistance? Arterioles. That's why I said that pre-capillary resistance. +31  
cr  the main difference between the 2 cases is that in this case the patient has high BP +1  
link981  So in kindergarten language the question is essentially asking how high pressure in the arterial system is NOT transmitted to the venous system (which is where EDEMA develops). But you know they have to add all this info to try confuse a basic principle and make you second guess yourself. (Got it wrong by the way) because of what @ferrero said of Qbank questions. +6  
hello  @ferrero what are you talking about? lymphatic drainage is the wrong answer... +1  
hello  ok never mind. i got it. hard to understand b/c it was a big block of text. +2  
asteroides  I think they may be talking about the myogenic compensatory mechanism: https://www.ncbi.nlm.nih.gov/books/NBK53445/figure/fig4.1/?report=objectonly "Increased arterial or venous pressure also induces myogenic constriction of arterioles and precapillary sphincters, which raises arteriolar resistance (thereby minimizing the increase in capillary pressure) and reduces the microvascular surface area available for fluid exchange. For example, because vascular smooth muscle in arterial and arteriolar walls contracts when exposed to elevated intravascular pressures, this myogenic response increases precapillary resistance and protects capillaries from a concomitant rise in their intravascular pressure." +3  


submitted by seagull(1443),
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hTe smsa si ni het reout rpeup nad,utarq tsih si hwy it wtna I.DCS iNec nad eipsml

seagull  *wasn't +  


submitted by haliburton(209),
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FA :7012 H oprily si stsoicedaa ihwt gsircta aioadacroencnm dna MATL moplahmy

seagull  I might be mistaken but I also thought Epstein Bar Virus was also implicated in gastric lymphomas? +11  


submitted by seagull(1443),
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tC44cMm/hwt/:/mwl9ocniw/g9p/inislbh6rcva.s8.9ep.nt/P.

Agodrcnic ot stih r,ppae rmuatpoPts oTtsrdiyihi sptrenes tiwh aitOPTn- nioatbi.dse ehT nrwesa eihcco sesu e.slphmyycot So iths si a tnsiraetn ositsoHahm tsoymHipyi.derrh dooG kLuc hwti that oen!

seagull  EDIT: Lymphocytes are also present in this as well. My bad +1  


submitted by mattnatomy(41),
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I tgtuhho anltiiyli we ewer dgenail with mstt-ourpap shsois,pyc but no dragrene-i, hits lsoko oemr ielk rhiete iaerdznGele yetxnAi iDrrdeos or OCD ro bot.h herEit ay,w mtrattene hosldu eb na ISSR er)Srina(et.l

seagull  OCD for sure +15  


submitted by oznefu(21),
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m’I aghniv teuobrl udnditnrsngae why siht si a ertebt hiecco ahnt etPag seda,sie yleaspecli iwth eht naeredics PAL?

zelderonmorningstar  Paget’s would also show some sclerosis. +4  
seagull  ALK is increased in bone breakdown too. Prostate loves spreading to the lumbar Spine. It's like crack-cocaine for cancer. +24  
aesalmon  I think the "Worse at night" lends itself more towards mets, and the pt demographics lean towards prostate cancer, which loves to go to the lumbar spine via the Batson plexus. I picked Paget but i think they would have given something more telling if they wanted pagets, histology or another clue +1  
fcambridge  @seagull and aesalmon, I think you're a bit off here. Prostate mets would be osteoblastic, not osteolytic as is described in the vignette. +16  
sup  Yeah I chose Paget's too bcz I figured if it wasn't prostate cancer (which as @fcambridge said would present w/ osteoblastic lesions) they would give us another presenting sx of the metastatic cancer (lung, renal, skin) that might point us in that direction. I got distracted by the increased ALP too and fell for Paget :( +1  
kernicterusthefrog  @fcambridge, not exactly. Yes, prostate mets tends to be osteoblastic, but about 30% are found to be lytic, per this study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768452/ Additionally, the night bone pains point to mets, and Paget's is much more commonly found in the cranial bones and appendicular skeleton, than axial. This could also be RCC mets! +  
sweetmed  I mainly ruled out pagets because they said the physical examination was normal. He would def have other symptoms. +4  
cathartic_medstu  From what I remember from Pathoma: Metastasis to bone is usually osteolytic with exception to prostate, which is osteoblastic. Therefore, stem says NUMEROUS lytic lesions and sounds more like metastasis. +5  
medguru2295  If this is Metastatic cancer, it is likely MM. MM spreads to the spinal cord and causes Lytic lesions. It is NOT prostate as stated above. While Adenocarcinoma does spread to the Prostate, it produces only BLASTIC lesions. +  


submitted by moloko270(65),
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.i.mc2gpd/w5i7nww/ho8v:mlnb2/us.tenh8/t.p0b

"odmrnesy fo diuito"llan o"yamopsyl-itloh ni evesre gecnovties aehrt aielufr yma be usdcea yb an aipotrrilyppnea gihh DHA cseronite ni iwchh hte setpocooerrm ssytem is mdaonited by rsomnolnao lsium"it

hayayah  Apparently, in chronic CHF you see hyponatremia. Because CHF causes a decrease in cardiac output and circulating blood volume, which in turn triggers a compensatory response aimed at preserving blood pressure. This stimulates the body to retain both water and sodium. +7  
seagull  i agree with Hayayah... the RAAS system is activated due to poor perfusion to the kidney due to decomp heart failure. +4  


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latgnAkyli anesgt t)hrach(remlneemoi eht( ehotr ugrsd sltied ear mbeuotilcur tnroiih)bis iaseenrc the ikrs fo MA.L

keycompany  Additionally, AML is the only answer choice that has multiple blast forms (myeloblasts, promyelocytes, etc.). ALL is characterized by a single blast form (lymphoblasts). +27  
seagull  CML has blasts too but they tend to favor mature forms. +4  
kash1f  You see numerous blast forms == AML, which is characterized by >20% blasts +8  
keycompany  The answer choices are all of lymphoid origin except for AML and Hodgkin Disease. We know Hodgkin Disease is a lymphoma (not leukemia) and would present with lymphadenoapthy. So the answer must be AML #testtakingstrategies +12  
impostersyndromel1000  @atstillisafraud thanks for mentioning the merchlorethamine increasing risk for AML, i was trying to make a connection with the drugs but couldnt. Had to lean on the test taking skills just like key company +1  
sweetmed  Procarbazine is alkylating as well. +  
pg32  @keycompany how did you know the phrase "multiple blast forms" meant literally different types of blasts and not just many blast cells were seen? +3  
castlblack  this link says CLL has 'large lymphocytic variety' under the picture of the peripheral smear. I am not arguing against you, just researching here https://emedicine.medscape.com/article/199313-workup +  
jurrutia  @keycompany, how did you know it had to be of myeloid origin? +  


submitted by keycompany(301),
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wolF Reta = leyVtcio x Crcnos-tloieSas Aare

2 c^2m x 20 sme/cc x 60 cnei/ms x 1 00,/01L m^3c = .42 /Lnmi

0,001 ^3mc = 1 L

seagull  Well, I missed this one. I don't even feel bad. +58  
link981  @keycompany a small typo, 100 cm^3 = 1 L not 1000cm^3. 1000 mL^3= 1 L +  
hello  @keycompany how did you edit your original comment to fix your typo? +  
winelover777  Pretty sure @keycompany was correct. 1 L = 1000 cm^3. Otherwise the answer would be 24. +3  
drdoom  1 centimeter is a distance. (A line.) +  
drdoom  If we multiply a line by another line, we get a surface area. (A piece of paper.) +  
drdoom  If we multiply the piece of paper by another line, we get volume. (A cube. A box.) +  
drdoom  If we fill the box with a fluid, we will have 1 mL of this fluid. +  
drdoom  If we have a thousand of these boxes, we have 1 L of fluid. +  
drdoom  1,ooo mL = 1 Liter = 1,ooo centimeterΒ³ +  


submitted by neonem(556),
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omFr wheeotca.nrtccm nerv(e aredh fo it oebref utb seesm ielk a dogo epa:nt)anxloi

a"ehsP IV iesut,ds eftno ecdlla tosP agktiMner ilencruvlaeS as,irTl ear ecotundcd aftre a ugdr or vieedc has been eaorppdv fro reocusnm lsea. tulichmaeacraP npocmieas evah vraesle jebetisovc ta sthi gatse: (1) ot amoerpc a grdu thiw teroh dgrus deyrlaa in eth rkm;aet 2)( ot otnriom a 'srudg -gnetrlom eistcenvffese and mtapic on a anseiptt' auqylti fo f;lei nda 3)( ot rineeetdm teh fnevisoeeestcsc-tf fo a udgr pytreha arleeivt to etroh ratitlaodin nad wen tipeah.ers aehPs IV sstduie can sleurt ni a ugdr or cvieed nbeig tknea fof hte aemktr ro cirsseottinr of esu duclo be edlacp no het utcpord dinpeedng on teh signinfd ni the "ytdsu.

seagull  Well, I was not smart and put phase 1 since it was talking alot about adverse effects and withdrawl from the patients. But now I see I have 2 extra chromosomes...my bad. +  
link981  Phase 1- Determine if drug is SAFE Phase 4- Continous surveillance of a drug that is already on the market. The vignette clearly states the drug is marketed. That means it passed the clinical trials. Marketed drugs have passed Phase 3 +  


submitted by mcl(586),
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iThs image si evry .lhlepfu

seagull  http://www.siumed.edu/~dking2/erg/GI178b.htm Another histology slide with labels +1  
masonkingcobra  I like to think that the parietal cells look like "fried eggs" classically +  


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’Its euatc aolhcol uocnoistnpm os ytatf gnache rmeo .lieykl rllelaCu llngeisw iiteasdcn aohccllio ieittsahp ciwhh iqurseer nohricc hlocalo oitmcsopunn (eeS FA 1902 gp )5.38 At saelt h’tast het cliog I edus ot ipck tyaft .gnhcea

seagull  Seems like fatty change would require more than 1 weekend. I choose swelling since it's reversible and seems like something with a quick onset. +40  
nc1992  I think it's just a bad question. It should be "on weekends" +16  
uslme123  https://webpath.med.utah.edu/LIVEHTML/LIVER145.html +20  
uslme123  So his hepatocytes aren't dying ( ballon degeneration ) vs just damaged/increased FA synthesis due to increased NADH/citrate +  
sympathetikey  @seagull I agree! +  
et-tu-bromocriptine  It's not in pathoma, but I have it written in (so he or Dr. Ryan may have mentioned it) - Alcoholic hepatitis is generally seen in binge drinkers WITH A LONG HISTORY OF CONSUMPTION. +  
linwanrun1357  Do NOT think the answer of this question is right. Cell swelling make more sense! +1  
fkstpashls  some asshole in suspenders and a bowtie definitely wrote this q, as I've seen both acute swelling and fatty change be used to describe one episode of drinking. +12  
msw  short term ingestion of as much as 80gm of alcohol (six beers) over one to several days generally produces mild , reversible hepatic steatosis . from big robin 8th edition page 858. Basically to develop alcoholic hepatitis with cellular swelling etc you have to have sustained long term ingestion of alcohol while steatosis can develop with a single six cap . hope that helps . ps i got it wrong too . +1  
msw  six pack8 +  
mariame  After even moderate intake of alcohol, lipid droplets accumulate in hepatocytes increasing with amount and chronicity of alcohol intake. (...) Fatty change is completely reversible if there is abstention from further intake of alcohol. The swelling is caused by accumulation of fat, water and proteins. Therefore this will occur later. From big Robins 9th pg842. +  


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"Uopn iacaoinptpl of rpressue ot eth rinalnet dne of eth vir,exc cointoyx is eledaser hftreeer(o enrcasie ni ctinelaotcr s)tpnore,i ichhw ulisatetms trnieeu intosccn,oatr hiwhc ni utrn eiscaensr sesepurr on eht ivxrec th(reyeb gansnieirc nciootxy aesler,e .e),ct uitln hte ybba is id.dvleere

senySor oiiomrtannf ggrdnreia cealhcainm hsrtcte of eth xerivc si rdierca ni a yssnreo ,ruoenn ciwhh sepsansy ni the daorls rhno bfoeer naiecnsgd ot hte barni ni eht eltrltaoanera coslunm pliaet(isral dan aneottralrcal ouert.s) Vai hte imnade aonrrifeb ,uldenb teh rntfefee aecersh teh PVN dna SON of eth pmyoah.hsatlu ehT proeotris apirtyuti arsleese yoonctxi edu ot ncaireesd irginf ni the lhooyymasa-hptahphepoyl tt.cra cOoyxnit sact no hte mommutryei, on orestrcep cwhhi aveh ebne reelauptgud yb a unoiafltnc siearnce fo hte ner-srtooeptgeersnego aroi.t ihsT cfotlaunin aorit gehcna is meeddtia by a esdcaree ni mirlmayeot etiisvyinst ot rrntoopgseee, due ot na niecsera in sreporegtneo ocpertre ,A adn a ncoenutcrr irnecsae ni artylmmioe tvisesinyit ot rgetsneo, edu ot na ciesaern ni rteeosgn trrepoec Ξ±. isTh escuas mmoyaelitr nraotncitoc dna rhtufre toveipsi efkcbade on teh e"refx[]1.l

pogispweinu/exF.eagr/klr:khds/io_irfewtei/n.t

seagull  https://www.ncbi.nlm.nih.gov/pubmed/8665768 a counter argument for PGE if you chose that answer. However, the author believes oxytocin is superior. +  
usmleuser007  1) PGE rises initially that causes the uterine contractions= this would be equivalent to when someone say #of contractions per time period. 2) Oxytocin is increased when the cervix is manipulated (ie. the birth canal reflex). +6  
jennybones  Please why is estrogen not the answer, I thought estrogen would upregulate oxytocin receptors and increase oxytocin secretion? +  


submitted by jotajota94(14),
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APD oflsw rmof atoar ot moruylnap ryaret ersidanegc ethoerlffrdeeora. aT aicdcar ttpuuo esarnices

seagull  doesnt pre-load also decrease which would drop the C.O.? +  
hungrybox  @seagull I think it would increase preload b/c more blood is going into the pulmonary arteries -> lungs -> pulmonary veins -> eventually more blood in left atrium/ventricle -> inc preload +51  


submitted by mcl(586),
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iDteodl is veeanrndti by lryaialx en,erv iwhhc mocse form otrso C./56C iAtsnco of teh ddlteoi iudclne ciotbunda fo het rupep yexetrimt.

seagull  I hope everyone memorized every single part of the brachial plexus and all the roots of each, No detail let untouched!!! +26  
mcl  In case anyone else has purged the whole brachial plexus from your memory (like me), this is a great resource linked by another user. https://geekymedics.com/nerve-supply-to-the-upper-limb/ +11  
zevvyt  I thought it was radial since he lost sensation in his thumb. If Radial is C5-T1, wouldn't that be included in C5-C6? +1  
alimd  they force us to know brachial plexus like the holy bible +  


submitted by danger_rave(-2),
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Mlpeutli lemaymo is an itseaolnpc onpefriraolit fo pmlsaa lec,sl adn senic msapal eclsl tond’ aevh rafescu gI bunod teal,nniy atth aws het onyl rueβ€β€œt ito.npo

seagull  Idiotypic means --- antibody against antibody. B cells don't have surface antibodies but mere synthesize them. +2  


submitted by haliburton(209),
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ouluBls iogpheidpm gnanite msut eb oeh.deosmemsim F:A bulla rea b"lwo"lu teh iemsrd ebleu(imradps rslb.e)it BP laos dylie "nst"ee .uallb

seagull  I love how this cant be straight forward. All the other proteins are either subunits of desmosomes or cytoskeletal components. Because I know molecular biology that well on top of the majority of medicine....FML +9  
cienfuegos  @seagull: excellent comment, literally loling right now +  
cienfuegos  or sobbing and threatening to hold my breath if they don't make it stop +1  
daddyusmle  WHY DIDN'T THEY JUST PUT HEMIDESMOSOMES THE FUCK +11  


submitted by beeip(123),
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I hgtim be teh lnyo orensp no aterh who tog shit eon gwo,rn tub eesd:rragls

I"TT nsisalay slidcuen evrye stuejcb owh is enddmraioz rncigdaoc ot ddmzroaeni metrantte t.imgnasens It ensroig c,nlncpoainmoe lroptcoo iov,astiedn rwtaiadlwh, and gnhtaniy taht hapsenp eartf nio"aiaotzmrdn.1[]

yo  You're not. I also goofed. +19  
seagull  https://www.youtube.com/watch?v=Kps3VzbykFQ This video is a pretty decent explination worth your time on the subject. +2  
hungrybox  I got it right but I was only like 50% sure. So I appreciate it. +  
drdoom  ^ linkifying @seagull: https://www.youtube.com/watch?v=Kps3VzbykFQ +2  
teepot123  ^ same video above used when I analysed my form 20 q which I got incorrect at time, its very clear at explaining this, helping me get it correct on this form +  


submitted by rocmed(-1),
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natC' erlna llec cmrianoac eucsa vainions fo het learn ey,tarr iubtgstoncr lbdoo fowl lgse(tnuir ni a bitu)r, theebyr ugrgnptuleai SARA adn nagnirseic blood r?usspere

lispectedwumbologist  It is but RCC tends to present later in life (6th or 7th decade). In a 55 year old smoker, atherosclerosis of the renal artery is am much more common cause of bruits +  
seagull  Hypertension is also a risk factor of an atherosclerosis leading to more inflammation. Eventually dilation (aneurysm) might occur... if im wrong then ignore this +1  
seagull  Hypertension is also a risk factor of an atherosclerosis leading to more inflammation. Eventually dilation (aneurysm) might occur... if im wrong then ignore this +  
illogical  Renal Cell Carcinoma has a tendency to invade the Left Renal **Vein** (Pg 134, Pathoma 2018). Thus it has an association w/ obstructed drainage of the Left Spermatic Vein leading to a varicocele. Renal artery stenosis is more commonly due to atherosclerosis (almost 85-90%) or fibromuscular dysplasia. +15  
ratadecalle  With RCC and renal vein invasion you would see B/L lower edema and venous collaterals in the abd wall (Uworld). Also he has a severe headache and confusion which are signs of a hypertensive emergency. +1  


submitted by rocmed(-1),
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atn'C arenl clel rmiaccnao acuse asoininv of the anlre ar,etyr ncgbstrtuoi lodob fowl (sterinulg ni a ,bru)it byeehrt glnpgrtueuia RASA dan iirnngeacs lbodo re?ssrpue

lispectedwumbologist  It is but RCC tends to present later in life (6th or 7th decade). In a 55 year old smoker, atherosclerosis of the renal artery is am much more common cause of bruits +  
seagull  Hypertension is also a risk factor of an atherosclerosis leading to more inflammation. Eventually dilation (aneurysm) might occur... if im wrong then ignore this +1  
seagull  Hypertension is also a risk factor of an atherosclerosis leading to more inflammation. Eventually dilation (aneurysm) might occur... if im wrong then ignore this +  
illogical  Renal Cell Carcinoma has a tendency to invade the Left Renal **Vein** (Pg 134, Pathoma 2018). Thus it has an association w/ obstructed drainage of the Left Spermatic Vein leading to a varicocele. Renal artery stenosis is more commonly due to atherosclerosis (almost 85-90%) or fibromuscular dysplasia. +15  
ratadecalle  With RCC and renal vein invasion you would see B/L lower edema and venous collaterals in the abd wall (Uworld). Also he has a severe headache and confusion which are signs of a hypertensive emergency. +1