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 +1  (nbme22#33)

Testicular biopsies of adult males with Klinefelter syndrome are characterized by extensive fibrosis and hyalinization of the seminiferous tubules and hyperplasia of the interstitium; however, the tubules may show residual foci of spermatogenesis. Histologic findings may include small, firm testes with seminiferous tubular hyalinization; sclerosis; and atrophy with focal hyperplasia of mostly degenerated Leydig cells


 +0  (nbme21#7)

Orchiectomy: One or both testicles is removed through a small cut in your scrotum. tissue removal from body → no nutrients → cell death

  • hall mark of cell death = DNA fragmentation

 +0  (nbme21#35)

Heart failure: This is the most serious complication of large arteriovenous fistulas. Since your blood flows more quickly through an arteriovenous fistula than it would if your blood flowed through a normal course of arteries, capillaries and veins, your heart pumps harder to compensate for the drop in blood pressure (called high-output heart failure). Over time, the increased intensity of your heart's pumping can weaken your heart muscle, leading to heart failure.

 +0  (nbme21#39)

Time, place, name → assesses orientation → to see if pt is for example intoxicated or not

Decision making capacity is based off of whether the patient understand her diagnosis and is making an informed consent → she knows and understands

 +3  (nbme21#18)

During the Mental Mini State Exam (MMSE), a health professional asks a patient a series of questions designed to test a range of everyday mental skills. The maximum MMSE score is 30 points.

-20 to 24 suggests mild dementia -13 to 20 suggests moderate dementia -less than 12 indicates severe dementia.

 +4  (nbme21#16)


Look at where the cusps are pointing → upwards therefore aortic. if cusps were downward → then mitral valve would be the right answer

 +0  (nbme21#20)

We can rule out A B and C because its cancer and pt will present w/ weight loss. Here the pt likely has pneumonia w/ elevated leukocyte count indicating infection. On PBS, cells look like neutrophils (seen in acute inflammatory states) which are granulocytes therefore it is reactive granulocytosis.

 +1  (nbme20#18)

In postobstructive diuresis the Urine is usually hypotonic with large amounts of sodium chloride, potassium, phosphate and magnesium [3] Urine Output > 125 - 200mL/hour after relief of obstruction for at least 3 consecutive hours[4] Urine Osmolarity > 250mosm/kg [5]


 +0  (nbme20#13)

The reported incidence of Caplan syndrome is 1 in every 100,000 people. This has been a declining number due to lower exposure to coal, asbestos, and silica. Prevalence of Caplan syndrome is higher in patients with silica exposure compared to the other causes. The first epidemiologic study undertaken by the Pneumoconiosis Research Unit observed an increased prevalence of RA amongst men with progressive massive fibrosis (PMF). Miall et al. found no increased prevalence of rheumatoid arthritis in miners when compared to a community where PMF and rheumatoid arthritis were prevalent and therefore concluded that the etiology of RA was not associated with exposure to dust or lung changes of complicated pneumoconiosis. There was a high prevalence rate of PMF and tuberculosis amongst miners and ex-miners with rheumatoid arthritis.[4][5]

Pathophysiology: An autoimmune condition is a phenomenon where one's body has inflammatory cells which attack its own tissue and, in the case of RA, the synovium. It is believed that in these patients, there is an alteration which causes the increased immune response to foreign materials in the lungs. There is immune hyperactivity that is sparked by silica in which monocytes and macrophages release cytokines such as interleukin-1 and granulocyte-macrophage-colony-stimulating factor and tumor necrosis factor alpha. The sharp edges of the silica also cause lysis of lysosomal proteases in macrophages. Lymphocytes are activated by the cytokines released by macrophages. This all leads to an autoimmune phenomenon through exposure to silica which is triggered in genetically predisposed individuals who have RA.

wouldn't the underlying disease be RA which is then causing bronchogenic carcinoma? I'm confused!!

kpjk  i dont think its RA, because they said xray shows new bone formation, where as RA would have erosion

 +2  (nbme20#8)

Widening of the = ANEURYSM!

Extra lumen in media of aorta = DISSECTION

THIS pt has an aortic dissection

1 RISK factor is Hypertension!!

(syphillus would be correct of the pt had an aneurysm but HIS CHEST X-RAY DO NOT show widening of the aorta)

 -2  (nbme20#14)

Anything upper lip + above → basal cell carcinoma

Anything lower lip → Squamous cell carcinoma

FA 2019 -pg 473

adong  it's saying upper vs lower lip. this pt has it on the nose

 +0  (nbme20#36)

sOn EMB Agar, isolated colonies of lactose-fermenting bacteria appear brown to blue-black in color. Escherichia coli appears as large, blue-black colonies, often with a green metallic sheen. Enterobacter spp. present as brown to blue-black, mucoid colonies with no sheen. Non-lactose-fermenting colonies, such as Shigella spp. and Salmonella spp., appear transparent and colorless.

We basically needed to correlate that → no organisms seen but only neutrophils to being a lactose non-fermentor organism. Therefore the answer is Shigella and not E coli

 +0  (nbme20#15)

Capsaicin induces the release of substance P, one of the principal chemo-mediators of pain impulses from the periphery to the central nervous system (CNS). After repeated application, capsaicin depletes the neuron of substance P and prevents its reaccumulation.

 +0  (nbme20#31)

Sciatica is a debilitating condition in which the patient experiences pain and/or paresthesias in the distribution of the sciatic nerve or an associated lumbosacral nerve root. Often, a common mistake is referring to any low back pain or radicular leg pain as sciatica. Sciatica is specific to the pain that is a direct result of sciatic nerve or sciatic nerve root pathology. The sciatic nerve is made up of the L4 through S2 nerve roots which coalesce at the pelvis to form the sciatic nerve. At up to 2 cm in diameter, the sciatic nerve is easily the largest nerve in the body. Sciatica pain often is worsened with flexion of the lumbar spine, twisting, bending, or coughing. The sciatic nerve provides direct motor function to the hamstrings, lower extremity adductors, and indirect motor function to the calf muscles, anterior lower leg muscles, and some intrinsic foot muscles. Also, indirectly through its terminal branches, the sciatic nerve provides sensation to the posterior and lateral lower leg as well as the plantar foot.

Any condition that may structurally impact or compress the sciatic nerve may cause sciatica symptoms. The most common cause of sciatica is a herniated or bulging lumbar intervertebral disc. In the elderly population, lumbar spinal stenosis may cause these symptoms as well. Spondylolisthesis or a relative misalignment of one vertebra relative to another may also result in sciatic symptoms. Additionally, lumbar or pelvic muscular spasm and/or inflammation may impinge a lumbar or sacral nerve root causing sciatic symptoms. A spinal or paraspinal mass including malignancy, epidural hematoma, or epidural abscess may also cause a mass-like effect and sciatica symptoms.

 +3  (nbme20#19)

Etiology → Cigarette smoking is major risk factor (50-80% of cancers, risk associated with duration and intensity) Also arylamines (2-naphthylamine) and aniline dyes In developing countries, Schistosoma haematobium ova are deposited in bladder wall and cause chronic inflammation, squamous metaplasia, dysplasia; 70% of tumors are squamous cell carcinoma HPV may cause condyloma, squamous dysplasia, squamous cell carcinoma sequence Phenacetin use (usually long term use in younger women, tumors involve upper collecting system) Chronic urinary tract infection and calculi Rarely cyclophosphamide with long term use

 +1  (nbme20#26)

The 3 main proteins that carry the majority (>95%) of Thyroid Hormones (TH) are thyroxine-binding globulin (TBG), transthyretin (TTR, or prealbumin), and albumin. A minor proportion of the THs is bound on serum lipoproteins. Very rarely, and in the context of anti-TH antibodies in autoimmune thyroid disease, immunoglobulins also may bind TH. TH binding to TBG is characterized by low capacity but high avidity; the converse is true, ie, high capacity but low avidity, for TH binding to TTR and albumin.

A deficiency in TH-binding proteins is suspected when abnormally low serum total TH concentrations are encountered in clinically euthyroid subjects in the presence of normal serum thyrotropin (ie, thyroid-stimulating hormone [TSH]). More specifically, low TBG is suggested because this protein carries the majority of the serum TH.

Several states of deficiency of this protein have been described that are either inherited or acquired. Thyroid function tests (TFTs) in patients with TBG deficiency show normal TSH and free T4, but low total T4 and, occasionally, low total T3 serum concentrations. The most important clinical aspect of TBG deficiency states is recognition of these disorders and avoidance of unnecessary and potentially harmful TH replacement therapy.

Subcomments ...

submitted by seagull(562),

THis question is just critical thinking. The adrenals are bilaterally and symmetrically small. All other answer choices are not likely to be even bilaterally. Cancer won't equally spread in perfect symmetry nor infectious causes while maintaining the adrenal architecture.

slim23shady  Will TB be the answer if they'd mentioned the patient from developing world? +  
step1soon  Autoimmune adrenalitis aka addisons disease → adrenals atrophy common cause: 1. developing world: TB 2. Western world:autoimmunne FA 2019 page 334 +3  

submitted by bubbles(38),

For the peeps who got confused on this question bc of UWorld's weird question on HIV viral load:

acute HIV-1 infection: HIGH viral load, low Ab HIV-2 infection: LOW viral load, low Ab (bc standard HIV assays detect p24, which is not present on HIV-2)

Kinda annoyed I missed an easy immunology concept question :/

eacv  I feel you my friend! same stupid mistake over here -.- +  
step1soon  FA 2019 pg 176 +  

My thought process was that post-partum bleeding is usually related to the uterus, and much of the pelvic viscera is supplied by branches of the internal iliac artery.

neonem  This sounds like a case of acute endometritis. In any case, uterus is supplied by uterine artery (branch of internal iliac artery) with collateral flow from ovarian artery (comes right off aorta). I don't think there are any branches of external iliac artery into the pelvis; it becomes femoral artery once it passes under inguinal ligament. +3  
tsl19  Here's a picture that I found helpful [Female Reproductive Tract arterial supply] (https://teachmeanatomy.info/wp-content/uploads/Blood-Supply-to-Female-Reproductive-Tract.jpg) +8  
sympathetikey  @tsl - Thank you! +  
step1soon  uworld Qid:11908 +  

submitted by egghead(1),

This is one of those questions I was never going to get. It's not in FA, I don't think I've seen it in class.

hungrybox  same :( +  
masonkingcobra  My issue was the stem said no skin damage (I would think pulling out your hair damages your scalp) [Turns out it does not](http://onlinelibrary.wiley.com/doi/full/10.1111/j.1529-8019.2008.00165.x) +  
gh889  FA 2019, pg 551 +4  
meningitis  Compulsively pulling out one’s own hair. Causes significant distress and persists despite attempts to stop. Presents with areas of thinning hair or baldness on any area of the body, most commonly the scalp. Incidence highest in childhood but spans all ages. Treatment: psychotherapy is first line; medications (eg, clomipramine) may be considered. +3  
step1soon  FA 2019 pg 551 +  

submitted by egghead(1),

What is with the picture? I just would never pick diverticulitis without seeing a diverticulum...

quaper  I spent so long looking at that picture and thinking what the heck are they trying to show me here. I couldn't see any diverticuli, didn't see any cobblestoning, figured the dark patch in between the white patches was necrosis in the end. +2  

submitted by lianallado(1),

Schizoid personality disorder is characterized by voluntary social withdrawal, limited emotional expression and social isolation.

step1soon  Answer is not avoidant personality because these people actually desire relationships whereas schizoid personalities do not (they are content with being loners-like this pt) +  

submitted by hayayah(525),

Patient has congenital hypothyroidism (cretinism). Findings: pot belly, pale, puffy-faced, umbilical hernia, macroglossia, hypotonia, poor brain development (MC cause of treatable mental retardation), large anterior fontanelles.

whossayin  how can you differentiate the symptoms of cretinism from Down syndrome? +  
step1soon  @whossayin Down Syndrome: upslanting palpebral fissures, atlantoaxial instability, bent little finger, congenital heart disease, displacement of the tongue, excess skin on the back of the neck, flaccid muscles, hearing loss, immune deficiency, low-set ears, mouth breathing, obesity, obstructive sleep apnea, polycythemia, seborrheic dermatitis, single line on palm, thickening of the skin of the palms and soles, thyroid disease, or vision disorder +  

submitted by hpsauce(0),

I believe this is Caplan Syndrome (bronchogenic carcinoma + rheumatoid arthritis). Only flaw to that is that the pulmonary findings don't perfectly represent pneumoconioses.

dbg  it's just bronchogenic ca, type of adenoca, which is classically associated with 'hypertrophic osteoarthropathy' +  
woodenspooninmymouth  To get it for the test, remember that lung adenocarcinoma is associated with clubbing. Mechanistically, this woman probably had RA. Then she was exposed to asbestos. The asbestos in the context of RA lead to caplan syndrome. The asbestos also triggered her bronchogenic carcinoma. +  
step1soon  Then why isnt Rheumatoid Arthritis right? what comes first? bronchogenic carcinoma or rheumatoid arthritis? +  

submitted by cienfuegos(20),

Couldn't you also decrease the FIO2? Per FA, CPP also increases to hypoxia also decreases CPP when PO2 < 50 mmHg.

cienfuegos  Obviously not the BEST option in this scenario, but seems like it could work unless I'm missing something. +  
step1soon  Its primariy driven by PCO2! only when O2 levels drop <50 mmhg is when the body responds to low O2 pressures +1  

submitted by xw1984(1),

I got this Q wrong. I was wondering why this patient “has no personal or family history”. Hereditary spherocytosis should be a AD disease, so, generally speaking, this diz should be seen in each generation, right?

step1soon  I was thinking the same! +  
wuagbe  Several genetics questions on NBME20 appear to be trying to throw us off by changing the descriptions of inheritance, leaving us to assume incomplete penetrance, smh. +