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Welcome to suckitnbme’s page.
Contributor score: 116

Comments ...

 +4  (nbme18#43)

Not very clear, but petrolatum aka petroleum jelly is used as a barrier so stuff doesn't get into the wound when the skin is compromised. This helps with anti-microbial defense and wound repair.

 +3  (nbme18#44)

X-ray shows a fracture of the surgical neck of the humerus. This where the axillary nerve and the posterior circumflex humeral artery travels.

 +5  (nbme24#41)

Even if you can't interpret the blood smear, this patient is presenting with malaria after being in the US for 1-year. It's highly unlikely that he got newly infected while in the US. What is occurring is a reactivation of dormant malaria (hypnozoites in the liver) that this dude got while in Honduras.

As such this is plasmodium vivax/ovale. What probably happened was that this patient was treated with chloroquine when he was initially infected. This would clear the infection in the bloodstream, but does not kill the hypnozoites in the liver. Treatment with primaquine is needed to clear the hypnozoites, which this patient likely did not receive, hence malaria while in the US.

 +4  (nbme24#40)

There are two types of pneumococcal vaccines for Strep pneumoniae.

The pneumococcal conjugate vaccine (PCV13) is given to children under 5. It is also given to adults age >=65 who are immunocompromised (PPSV23 is also given afterwards).

The polysaccharide vaccine PPSV23 is given to adults, the indications for which I won't go into.

Since this patient is 2-years old he should have received the conjugate vaccine per CDC guidelines.

 +1  (nbme24#31)

POMC is a prohormone peptide chain that gets cleaved into gamma-MSH, ACTH, gamma-lipotropin, and beta-endorphin. There's a nice figure of this in Costanzo (Fig 9-10).

It may help to remember that pathologies with increased ACTH (ie Addison's disease) can present with hyperpigmentation since MSH (melanocyte stimulating hormone) is produced alongside ACTH.

 +0  (nbme24#3)

Tfw NBME said there's no repeats on 23 and 24 and then you get a repeat.

 +2  (nbme21#16)

I was stuck between mitral and aortic and went with aortic because the L ventricle looks enlarged, possibly hinting that the patient had aortic stenosis.

drzed  I went with aortic because it looks like the valve has three cusps, while the mitral valve should only have two. Incorrect logic? +2

Subcomments ...

submitted by niboonsh(287),

external carotid branch supplies the superior parathyroid glands as well........?

yng  Yes the superior part supplied by superior thyroid gland which is a branch of external carotid branch. +  
llamastep1  No they do not, parathyroids are supplied by the inferior thyroid arteries. +8  
suckitnbme  Superior thyroid artery does supply some blood to the parathyroids through anastomoses but the main vascular supply is from the inferior thyroid artery. +  

submitted by sinforslide(40),
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hTe tiatepn ewldak trobafeo no eth ahebc dan hda s,hrsriico ciwhh asmek ihm levurealnb ofr .V fcinuisvlu ambe.irecat .V sufnuvicil rcameebtai sah a ryve proo ps.oosirgn

From aUoptet:d ."V[ ]nisulivfcu si the ileangd saeuc of elds-ahhieoasilsctsf sthdae in teh eitdUn S.ettas enictsIonf ued ot V. iufiuvcsnl ear toms cmonmo in indsldviaui who ehva rh,ncoci lrdgnenyui ne;lisls vsdniiadliu itwh lreiv sediesa or mesotohsrocaimh are ta eagterts "i.srk

sinforslide  Also see UWORLD ID: 15255 +3  
suckitnbme  Vibrio species are mostly non-lactose fermenters except Vibrio vulnificus +3  

submitted by breis(35),
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I am otn %010 no tsih enigb ctr,roec tbu I lbryife mrbemeer a tisrsiachyPt gsynia tath hte iettnap sah ot be eizruse erfe rof 6 othnms mummiin and drreferpe ot ehva no sruieze iwniht hte alst 3 rysae ot be o.tcamsipyamt Do twhi ttah omfnrainito tawh uoy ilwl. utb for rodsB:a 3 syre.a

suckitnbme  Question stem also implies that the patient has been driving already. "has not had any collisions while driving his personal motor vehicle". +1  

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iMld ancudjei thiw acrdsinee jngucanduote ni an eoldr lfeowl si eedaecdrs uU-ryrDroflunsalnaegstPec acvtyiti. aPrtcuaylril in ctnxeto of tssers pty(eocpem)and

pg32  Went with hepatitis because of his recent surgery. Seen problems like this before where recent surgery means they were given inhaled anesthetic that can cause hepatotoxicity/hepatitis. That, along with the elevated AST/ALT and unconjugated bilirubinemia (signifying liver losing its ability to conjugate bilirubin due to inflammation) made me pick hepatitis. Why is that wrong? +  
suckitnbme  @pg32 AST/ALT are only slightly elevated. The patient also is not particularly symptomatic. He's really not that sick. Hepatoxicity is also most associated with halothane which is no longer used in the US. It would be a different story if the patient had surgery done in a different country (as is common in Uworld questions on this) +3  
mumenrider4ever  I don't know why NBME uses ALT/AST reference ranges from 8-20 u/L when the reference ranges for uworld are 8-40 u/L. So maybe his liver enzymes aren't really elevated since they're below 40 +2  
cheesetouch  Can someone refute 'surgical trauma'? +  
cancelstep  Appendix is pretty far anatomically from the bile ducts. Also damage to bile ducts should cause direct hyperbilirubinemia since there's no problem with conjugation versus Gilbert syndrome which causes impairment of UGT +  

submitted by pg32(111),

Can anyone explain why the lipase concentration is so high if there is an issue with LPL in hyperchylomicronemia?

garima  due to pancreatitis +5  
neovanilla  ELI5? +  
suckitnbme  @neovanilla Type 1-hyperchylomicronemia has increased risk of pancreatitis +  

submitted by rainlad(19),

How do you rule out Protein C deficiency in this case? doesn't that also increase risk of thrombosis and miscarriage?

suckitnbme  @rainlad Protein C deficiency doesn't cause elevated PT and aPTT. I believe they're both normal and assays for the disease measure protein C activity. +4  
drzed  Protein C is an anti-coagulant, so if you lack factor C, then you have MORE clotting factors. This means that the PT and PTT would not be prolonged. +3  

submitted by majic(7),
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HTE STMO OOMNCM eurot of Toxo stamosninris ni austdl in the SUA is niigsoten fo udocreoekdn ko.rp Even fi cat lertti si na oonit,p coddeeuonkr oprk si llsti rome m.nomoc

yotsubato  Also another fun fact. Most people in France are infected by Toxo (like 80%) because of how they eat meat. (Very rare) +1  
madojo  To add on might be TMI but most people have Toxo but are asymptomatic because its in its latent form as a pseudocyst and its not untill you are immunocompromised that it strikes +  
suckitnbme  This patient also probably got toxo in Brazil +  
luciana  JFYI people in Brazil love to eat rare meat at barbecues +  

submitted by xxabi(224),
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Sentt orbtosmsih sv entSt rsioothmbs si an aetuc inscouocl of a rroncaoy aetyrr ,netts wcihh fnote tssluer ni cutea ryaoncro dsrnmoy.e anC eb erevdnetp by auld linpaetttael yhetarp ro ge-rulnigudt nse.stt Rtseni-oess is eht graaudl ngiorrnwa of het tsten uelnm due to inimleanto rit,aefopnirol ergnisult ni nlgnaia yspsmmot.

sunshinesweetheart  so just to clarify - it's the "symptom-free for 3 months" that rules out thrombosis? +2  
hpsbwz  It's moreso that at rest there's no changes, but during exercise there is. Like the pathophys of stable angina. +1  
suckitnbme  I think it's more because of the 2-month history of PROGRESSIVE angina sx with exertion. This points to a chronic process rather than an acute event. +  
alienfever  Drug-eluting stents prevent re-stenosis (rather than thrombosis) by releasing sirolimus which by blocking cell proliferation. +  

submitted by m-ice(272),
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The iatnpte hwoss no ings fo rtaciolc it,ayicvt but ash seom isbntarme tnfuocni a,ntcti hchiw peimils ehs is in a omrf fo stepenistr itveveaegt She ahs a lviign wlli tath dnseseagit ahmccanlei avitlntione hsoudl eb osnitendiudc fi tath utnatiios seiar,s os ew mstu flloow it nda mkae otn tteptma to estasce.trui

lfsuarez  Why would the second part of that be correct when there is not mention of a DNR? +10  
ug123  DNI and DNR are different right? This patient had a DNI. Why would we assume it to be DNR too? +2  
sherry  DNI and DNR are indeed different. But it is not the case here. The patient needs to be extubated means she did not sign a DNI or DNR in the first place. I assume her living will is more like terminate supporting treatment in a vegetative state. So there is no need to do resuscitation anyways. But I agree this is not a good question. +  
shayan  "The patient has signed the living will and is consistent with her directives" but the stem doesnt tell has what is in her living will about the extubation? we are extubating on the request of her husband? this is confusing ! +4  
criovoly  I believe this question was not well constructed... it's one of those! +  
suckitnbme  @shayan extubating at request of the husband because he's following what's in her living will. Following that line of thought, the patient probably wanted withdrawal of care if in a vegetative state. +  
luciana  I understood same as @shayan that she wanted to keep intubated... now reading it again I feel extra dumb with my poor reading interpretation skills +  
coldturkey  @lfsuarez CPR(if the need arises) , for this patient (barb overdose and hospital setting), she will be intubated to get and maintain airway access. However ,she is against any mechanical ventilation as per her living will. Hence, we cannot perform CPR on her. +  
furqanka  I too believe DNR and DNI are distinct but UW 1124 says - A DNR order indicates that a patient should not undergo CPR. this includes bls (mouth to mouth breathing, chest compression) as well as advanced cardiac life support (intubation, mechanical ventilation, defibrillation, and administering medications such as vasopressor or epinephrine). Additional wishes such as the desire to not be fed artificially or any other limitation of care can be specified. +  

submitted by charlie(9),

I think there's a typo on that question. MSH2 gene mutation is the culprit for HNPCC. For MHS2 gene, according to what I just searched, causes Malignant Hyperthermia Susceptibility.

noplanb  Yeah I think it should be MSH +  
suckitnbme  Good to know I wasn't tripping out when I did this question +2  
thisshouldbefree  $60 +2  

submitted by m-ice(272),
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GMH oAC adecteRus niibiohrst tvpneer eht rvile ormf ygsziinthnse sti onw slthoeer.loc In edrro to nmatniai sit eedn for elsorlct,eoh hte irvel sha on coecih yb ot aeisenrc sti DLL rrtepoec ssprinexoe in edrro ot take oeortelhlcs from hte ob.ldo

suckitnbme  Not sure why NBME felt like they needed two questions on statin MOA on this form. +5  
makinallkindzofgainz  because they didn't even realize it because they make insanely low effort practice exams with awful formatting and vague vignettes, yet here we are paying 60 bucks a pop for "high quality" exams, gimme a break. ok i'm done venting +3  
madden875  stop whining. no one asked you to buy the exam^ +3  

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owH od ouy tsghsinuiid shti from crtsitaleu t?nrosio Is it ustj bueeacs it ardetts ni the eltf n?kfla

neels11  and there's no mass in the scrotum, whereas testicular torsion will have that "bag of worms" feel (along with a lack of cremaster reflex) testicular torsion usually happens in a younger age group +8  
medpsychosis  @neels11 I would like to clarify a piece of information. I believe you are confusing Varicocele with Testicular Torsion. Varicocele will present with "bag of worms" feeling. While the absence of cremasteric reflex is a sign of testicular torsion. +8  
johnson  This is the classic "loin to groin pain" of nephrolithiasis. +3  
suckitnbme  Testicular torsion would also tend to have a unilateral high-riding testicle. +  

submitted by sangeles(8),

To me it sounds more like nevus simplex. The most common capillary malformation is nevus simplex, which affects more than half of infants. Nevus simplex, or “salmon patch,” lesions are pink, ill-defined patches that tend to occur in midline locations, most frequently on the nape of the neck, glabella, eyelids, nose/lips, scalp, and sacral region Historically, colloquial terms such as “stork bite” (nape) and “angel kiss” (forehead/glabella) referred to nevus simplex lesions in particular anatomical regions. Unlike PWS and most other vascular malformations, most nevus simplex lesions regress within the first 2 years of life Clinical differentiation of nevus simplex from PWS, especially on initial presentation, can be difficult. Lesions with lighter pink color, midline location, and indistinct borders favor nevus simplex.

suckitnbme  I agree that this nevus simplex and not a strawberry hemeangioma. Of note, nevus simplex lesions are flat lesions formed from dilated capillaries. Lesions on the face tend to regress while lesions on the back of the neck typically do not. +1  
misterdoctor69  The main thing that bothers me about this question is that if it is indeed nevus simplex, it's definitely a very non-typical presentation. Nevus simplex most commonly occurs on he back of the neck/midline locations plus they are pink in color. The lesion described in this question is purplish (not pink) and it appears on the right side of the face (ie. neither back of neck nor midline). We can definitely rule out nevus flammeus because that is only seen in the setting of Sturge-Weber syndrome, which this patient has no signs of. We can also rule out strawberry hemangioma because such a lesion would be raised, not flat. +2  

submitted by madojo(122),

Cyclosporin is an immunosuppressant that blocks T cell activation by inhibiting IL-2, so we know thats not right. Cyclophosphamide is an alkylating agent. Doxorubicin is an antitumor antibiotic that generates free radicals and causes breaks in DNA. 5'fluorouracil is associate with pyrimidine synthesis. Leaving Vincristine which is a neoplastic drug that works on microtubules (other drugs that do this colchicine, paclitaxel.

As mentioned already, the cell is stuck in metaphase and cannot undergo the seperation anaphase. M cycle arrest is associated with vincristine and which the mitotic spindle which is what separates the chromosomes is not forming.

suckitnbme  The funny thing is that the image seems to show that the spindle did in fact form. +7  
spaceboy98  EXACTLY They showed the mitotic spindle is formed, so paclitaxel would be ok, but for vincristine, the damn thing would not even form +1  

submitted by neonem(503),
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hTese aer guot slycst.ra I espposu het ebst yaw ot driefeitantfe tish asce morf segptuoduo is that teh lcratssy era rsaph ap;&m eedsnel-edhpa and tno hdrbmie-ohs.apod

sympathetikey  Yep. They tried to throw you off with the picture, but the wording in the stem says its a "photomicrograph" -- not exposed to plane polarized light, where you would see the negative birefringence. +14  
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +  
suckitnbme  @linwanrun1357 I highly doubt you would be looking at your own joint fluid aspirates instead of sending it to the lab. +2  
nnp  what those yellow white nodules signify? +  
peqmd  In clinic gout is typically a clinical diagnosis. If you can treat w/ NSAIDs instead of aspirate you would do that. You would aspirate if you are considering septic arthritis so you can get culture. I don't think anyone aspirate for heck of it. +  
lowyield  @nnp, the yellow white nodules are tophus which is a sign of chronic gout, characterized histologically by aggregates of uric acid crystals, can show up as skin nodules most commonly on external ear, olecranon bursa or achilles tendon (pg 467 FA 2020) +  

submitted by gonyyong(83),
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'sWtna suer tabuo oterh,s tbu ohrpmyamagm ofr rgelnea anpitlpoou s'nit edmneercdmo itlnu 40

_yeetmasterflex  Also wouldn't mammography be secondary prevention since you'd look for asymptomatic disease already present? +16  
suckitnbme  USPSTF recommends starting screening at age 50. 40 by patient choice if there's risk factors. +1  

submitted by ameanolacid(20),
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eohtcAsosrresli si eth MSTO nmcmoo ucase fo aernl reyatr ts.wo.tesh.isni suuircabmrfol ssdapaily egbin eht CDOENS tosm nomcom acsue v(nee toghhu ti is mpiegtnt ot ehoosc tihs itnopo inrcengsdoi het 'tapneist deg)cohpm.ira

xxabi  Is there a situation where you would pick fibromuscular dysplasia over atherosclerosis if given both options? Thanks for your help! +5  
baconpies  Atherosclerosis affects PROXIMAL 1/3 of renal artery Fibromuscular dysplasia affects DISTAL 2/3 of renal artery +36  
gonyyong  Why is there ↓ size in both kidneys? This threw me off +2  
kateinwonderland  @gonyyong : Maybe because narrowed renal a. d/t atherosclerosis led to renal hypoperfusion and decrease in size? +1  
drdre  Fibromuscular dysplasia occurs in young females according to Sattar Pg 67, 2018. +6  
davidw  Normally you will see Fibromuscular dysplasia in a young female 18-35 with high or resistant hypertension. She is older has a history type II DM predispose you to vascular disease and normal to moderate elevation in BP +5  
suckitnbme  @gonyyong there's bilateral renal artery stenosis. The decrease in size of both kidneys should be from atrophy due to lack of renal blood flow. +2  
tyrionwill  1 year ago, she did not present any physical or Lab abnormalities. This means she must not suffer fibromuscular dysplasia, otherwise she must have presented renal abnormalities for a long long time, or even before DM-2. +1  

submitted by gonyyong(83),
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The kid has aoatgyesimcn due to bretyup (scxees ttrteeseonos → rno)eghse Ttsi egso away altluaryn taneayplrp( ni 12 ot 81 osnht)m

I khitn you ond't veah to od boold tsets sueeabc eh has omnlra alsxue nvleetomepd orf shi ega dan rehet are on retho nsg?si

osler_weber_rendu  How does telling an "embarrassed kid" that he will have big tits for 12-18 months help?! +20  
howdywhat  my exact thought, telling him that it will last for somewhere around a year and a half doesnt seem so reassuring +1  
suckitnbme  I thought it was reassuring in that the kid is being told this isn't permanent as well as that this isn't something serious. It's important to inform him about the prognosis. +6  
thotcandy  "don't worry your gynecomastia isn't permanent, but the mental scars from the bullying you will receive in HS definitely will be :) good luck!" +2  
therealslimshady  What is the gynecomastia is from a prolactinoma? +  
misterdoctor69  @therealslimshady the gynecomastia is from the sudden surge of testosterone during puberty being converted into estrogen => more breast tissue. +1  

submitted by lsmarshall(348),
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ilapseatMa - A rvrblesiee atvediap seenosrp ni iwhch rteeh is mrgaRo"npgreim fo estm nllpceŽaetrlseecm of one ellc ptey yb oerhant ahtt nca daatp to a new sers"st. Btho ear mlorna ecsl.l yrRoripaets teer usolhd ont aevh uqosmaus llesc iultn psroeartiyr conesolbhir bfeo(er tha;t cobidalu ni .brno gt;& alcnuomr in nbr.coh &tg; ositpaurdetsidfe orcaulnm ni elagr.

shayan  if its a metaplasia, then how it be normal ? I mean Metaplasia is not normal? +1  
artist90  i got it confused bc the question stated that there was a mass in one lobe of lung and i didn't knew that squamous metaplasia also presents as a mass in lung. i missed that on biopsy they were clearly stating squamous metaplasia. +4  
suckitnbme  @shayan The term "normal" in the answer is used to indicate that the cells appear normal (meaning appropriate size/architecture/appearance). Remember that metaplasia is a normal response to stress. +4  

submitted by krewfoo99(75),

This could easily be confused with Squamous Cell Carcinoma as they are describing a mass. But i think the key difference is that they mention METAPLASIA. If it was dysplasia, then it would have been cancer.

usmlecrasherss  metaplasia also can lead to cancer FA p206 2019 +  
suckitnbme  Dysplasia is not cancer since it is, in theory, still reversible. Only when it becomes irreversible is it a carcinoma. +1  

submitted by snafull(4),
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naC yobmdsoe iaxlpen wyh hits is ton a feignor dbyo graaol?unm

yb_26  because they mention scattered fragments of foreign material (pt presents 2 months after c-section, sutures are either removed in 1 week or dissolve in few weeks (depends on type of suture material) +  
suckitnbme  I think it IS a foreign body granuloma. The sutures are supposed to be removed or dissolve but sometimes one gets left in. The question says foreign material and sutures are often polarizable. +5  

submitted by beeip(116),
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Can neayno pailnex htwa ht'eyer ttgineg at ?heer How nca oethcnbleha eb ieatdincd nda adedtacirtocnn?i

sniperx3  I think it's because Bethanechol acts on M3 receptors which can treat her urinary problems but it might exacerbate her asthma symptoms since there are M3 receptors on the lungs. +30  
suckitnbme  I definitely had to read this question multiple times to understand it. +1  
brotherimodu  I read it like 6 times and gave up +1  

submitted by sweetmed(123),
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heT mHa test si a tste eusd ni het nisagdios of yxpoamrlsa onrnctlau bhngaoeliouirm .H(N)P eTh tste vinlvoes ncpalgi edr dlboo sellc in dmil dc;ai a eiiovstp rlseut casren(ide BCR iyrgatl)if neidaisct NPH

suckitnbme  It's so obscure of a test that wikipedia only has 4 sentences on it. +1  
pathogen7  FA2020 added the Ham test to PNH I believe! +  
pathogen7  Whoops no sorry I am wrong. They did add something called the EMA test to spherocytosis though. +  
snripper  Ham test has been replaced by flow cytometry now. So fck off, NBME. +  
pseudomonalisa  I remember it like this: PNH occurs at night due to mild respiratory acidosis (slower respiratory rate), which activates complement which destroys RBCs. The test is essentially doing the same thing, putting cells into an acidic environment -> dead RBCs. +1  

submitted by neonem(503),
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nCnobpieletleoer egaln asms = brstuaeVli onwsmhcana A(KA csiuotac m)onu.are ivDrede mrfo nhcawSn le,slc hichw era of earlun cstre rnoiig.

yotsubato  Ugh. Of course they dont put schwann cells as a choice. So I pick oligodendrocytes like a dumbass +28  
subclaviansteele  Same^ +1  
madojo  Schwann cells = PNS Oligodendrocytes = CNS +2  
suckitnbme  NBME loves their neural crest cells +3  
wrongcareer69  How much do they pay these testwriters anyway? I can use a thesaurus too +  

submitted by urachus(11),

not EPO bc it's asking what's made from the bone marrow. EPO is from kidney

lilyo  Thanks, I was wondering why EPO was not correct. So EPO synthesis would be stimulated in case of blood loss? its just wrong becase they ask specifically what is going to be produced in the bone marrow? +1  
suckitnbme  @lilyo yes because it's specifically asking what the bone marrow is synthesizing. EPO would also be upregulated but this happens in the kidneys. +1  

submitted by drdoom(647),
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hTe stem si gbencdirsi esleaequ of eotsrproi irrneofi aceerllbre aryter siuo,lcocn ielustgrn ni eleWrgnlab de.nrymos eHs’er a inec teschicma of het aftfeced iulnce nda nrbia etsm gnois:re


... dna a 6tei-num ebuTuoY edvio ttha slawk yuo huhtrog i:t


nbme4unme  Great video! Very, very solid review of brainstem anatomy. +  
suckitnbme  This image was surprisingly interpretable for NBME standards +7  
aneurysmclip  and the fact that all you needed to know was the side of the lesion to answer tbh lmao, but other than that localizing to medulla wasn't hard. +3  
medguru2295  Actually, they were quite nice. You didn't even have to know what side. There was no option for left medulla. +2  

submitted by soph(49),
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I nkhti kye reeh si heyt aer einisgianvtgt eth hposysehit fo tomuman of siainrcne ratew snsraciee KRIS fo .ec.arn..c steb yaw ot asurmee rski is case lotnro.c

nbmehelp  If they were measuring risk shouldn't it be a cohort study though? By looking at first aid.. +2  
270onstep1  They both can determine risk. Key here is the time efficiency of case-control studies when compared to cohort. +  
suckitnbme  Case-control only determines odds ratio which is not calculating risk. In rare diseases the odds ratio can be used as an estimate of the risk ratio however. +  

submitted by keycompany(268),
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mgeaI wssoh Cnetcrse gSni, a noocmm gnidinf in anmbidAol trcAoi Aeryussmn ued ot lmuar urmsohtb uoc.sonicl

happysingh  crescent sign is a finding on radiographs that is associated with avascular necrosis, NOT aneurysms !!! what you're seeing is Calcification of wall of the aortic aneurysm +12  
sabistonsurgery  @happysingh - Thank you. You are correct indeed. +  
suckitnbme  Adding on, this patient is a >65 yo Male with a 120 pack year smoking history. Both are significant risk factors for AAA. +  

submitted by krewfoo99(75),

HPV has high affinity for squamous epithelium. True vocal cords have squamous epithelium, thus HPV tends to grow there

suckitnbme  Specifically stratified squamous epithelium I believe. +1  

submitted by nlkrueger(33),
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.... udowl ew yllrae teak eht wdor fo a derfni who fielienydt nc'at eb e?nrfcimdo I elef iekl shti is gnsidialem

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 +20  
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 hayayah(990),
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kWsn-rkfoearfoiKce Do'nt aveh ot be an lacoilcho ot tge ihs,t jstu yausllu si aleetrd ot iacloholms / iaimthen ccdeifniye.

d_holles  Yeah the negative EtOH screen threw me off +3  
dr_jan_itor  Why cant it be early alzheimers and hippocampus? She could easily have been a former prominent physician and member of city council. Am i supposed to assume that simply because shes disheveled and poor hygeine that she must be an alcoholic homeless person? It also mentions no symptoms of nystagmus, ataxia, etc. +2  
kimcharito  it said broad based gait and nystagmus +6  
lilmonkey  She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment. +  
fatboyslim  @ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus." +  
suckitnbme  NBME questions also stereotype the shit out of their patients +4  

submitted by rainlad(19),

would we be worried about using G-CSF given that he has acute leukemia? would it stimulate growth of his cancer cells?

suckitnbme  I think we're assuming that we eradicated the leukemia with the chemo. However at the same time a lot of normal stem cells were also killed off so we give GCSF to help recovery especially since they have an infection. +  

submitted by nuts4med(6),
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I asw tkninhig sron’Ch sabecue fo hte ornrwgnai fo hte mlnue nda het ruiectp seeedm klie ehret asw irecgepn taf. wNo atht I ktnhi oubta it h,uotgh teh LLQ dan ooiitcnsnpta huodsl heva edl odrtaws rcletiitdisuiv petryt uq.cykli

suckitnbme  Also agree the narrowing of the lumen plus the pic is pointing towards Crohn's. The acute systemic sx of fever and chills is what made me go with diverticulitis (along with the hx of increasing constipation). +1  
pg32  Why does the question say there is NARROWING OF THE LUMEN? Does that happen in diverticulitis? I went with Chron's at the last second against my better judgment because Chron's can cause strictures/narrowing of the lumen. +2  
lola915  FA 2020 pg.383 Most common area for Diverticulosis to take place is the sigmoid colon and diverticulitis can cause obstruction (inflammatory stenosis). The key here is recognizing the risk factors (>60, chronic constipation) and signs of acute inflammation (fever, chills and LLQ pain). +1  

submitted by hayayah(990),
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andyrSceo omyipthdyhieaparrrs allsuuy( td/ cchoinr areln .ieuf)alr

Lab insgindf lunicde ↑ PTH sos(repen ot wol cicmlau), ↓ esumr uamclci alern( ifrueal), ↑ eumsr shptoaehp elna(r rieafl)u, nda ↑ ankelail sspaahoepht HT(P ivgacttani ea.Bsossot)tl

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +1  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +1  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +1  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1  

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It siad ti wsa aatlf to lesam ni oetu,r and het toqueisn sekad baout evil rnbo gins.ffopr neicS eth alsem enat’r ebgin nrob ni eht sitfr ,lcpae I aids 05% laeefsm nad %0 .msela

hungrybox  fuck i got baited +26  
jcrll  "live-born offspring" ← baited +11  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  

submitted by yotsubato(806),
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hWy si isht OTN hacnird?oc Trhsee ngtonih ereh ahtt lesur it o.tu

drachenx  Chancroid is described as an ulcer.. whilst in this question they mentioned "vesicles". Pretty much only herpes is vesicular +5  
whoissaad  They mentioned ulcers too. I chose chancroid as well, couldn't find a clue to rule it out. Also thought "discharge" was pointing you towards a bacterial infection. But guess I'm wrong :) +  
emmy2k21  I think NBME/USMLE writers make the assumption the patient is in America unless specified otherwise. Chancroid is not common in the US. If the question stem mentions a developing country, then chancroid can make your differential list. +1  
selectuw  for chancroid, there may be a mention of inguinal lymphadenopathy +2  
samsam3711  Also with chancroid questions they want you to differentiate it between chancroid and syphilis, (eg. Painful vs. painless) and is usually described as a much larger ulcer that is painful (not vesicular as in this question) +  
suckitnbme  Also believe that chancroid does not presents with systemic symptoms like in this vignette. +  

submitted by welpdedelp(198),
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tI saw sse,ciba hwhci si snetattimdr o.neepnsr-poro

welpdedelp  **person-person lol +5  
suckitnbme  NBME loves their scabies +11  
dentist  did you get scabies from "burrows" and "night itching" +  
pg32  My question is where do you get scabies originally? I knew it was transmitted person-to-person, but thought it has to originate somewhere (a pet possibly?) so I went with pets. The internet only seems to say that you get scabies from another person with scabies, so the question remains: where do people contract scabies from? +  
leaf_house  @pg32 , long quote: + "Sarcoptes scabiei mites seek the source of stimuli originating from the host when they are off the host but in close proximity to it. This behavior may facilitate their finding a host if they are dislodged from it and contaminate the host environment. Thus, direct contact with an infested host may not be required for humans and other mammals to become infected with S. scabiei. In the case of human scabies, live mites in bedding, furniture, toys, and clothing can be a source of infection. Sarcoptes scabiei var. hominis have been recovered from laundry bins in a nursing home." + from here: +  
zevvyt  to summarize leafhouse: Fomites +1  

submitted by gh889(89),
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mFro nnuhryeokoSdakeHo on i:dtred

htWa hte nsoteiqu si ggeittn ta is eth smtyehptcia iacnh wsa as.rdpe tI asw a ertlrieb yaw fo ginowrd ti.

oYur rnotirea tymhoalhaups is lonbpeseris for cioolgn sefatuer dna si edunr meyrpactsapiaht ctlo.orn A esolin uowld eacsu raerhme.yhtip

rYuo ritepsoor hlamsopaythu si rnlobpeessi rfo atnihge hnew 'ouyre ldoc nda ot eartgene the erFve sprnoees nda is nrued hstcteipyam lt.nocro A eonlsi uwdlo uscae tmherpohi.ya

nI sthi inuseqto it is msiypl ikgans a pernos setg ,kcis ophtaaymhslu swa s,preda hawt hspnpa.e

swn:Aer myahlotauhsp ilwl ltlsi eb leab ot eaeevlt ets dbyo eeeartmprtu to tleabt ite.nnfioc

Hitn: IF htye egvi a squniote mrisail ot iths utb rrewodde ot niecudl a isonel of eth hiatctsyemp sfbire or fo hte lhmso,aytphau you owuld in urtn TNO be aleb ot gtreeena a erfve ernsepso ot hTe aotlsuhayhmp udlow eb tneiryle unerd heitaymsatprcap lcrotno

sihT dsda eomr xttenco ot eht tcfa eht Q stseta taht eth hetiapstymsc saw pardes

oslerweberrendu  So, this says sympathetic also spared and hypothalamus also spared. Then what was wrong with this clinical case?? +  
adong  i think the sympathetic system is actually impaired b/c it's cut before it can "outflow" least it's the only way this makes sense +3  
suckitnbme  I agree. I think the question stem is saying the sympathetics were lesioned. Not that they were spared. +3  

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migmoeannis nucot as nnhaiecgn sleoisn? ts(ih nemcomt desen ot eb roem tahn 05 certhrsaac )lppryneaa.t

goldenwakosu  I think it’s because meningiomas are able to calcify (aka sometimes they have psamomma bodies). I got this question wrong too but I totally did not completely register that the tumor was in the dura (interhemispheric fissure + central sulcus). Hope that helps! +2  
pipter  the only reason I got this right was because they described the tumour as being near the falx cerebri. +2  
fcambridge  Other hints include being described as round and seen in a female. Both indicative of Meningioma +11  
niboonsh  also meningiomas typically present with seizures or focal neurological signs +  
suckitnbme  I thought enhancing meant it uptakes contrast. Meningiomas are commonly enhancing lesions per Radiopaedia. +  

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urO tlltie nfdier has a avrruvosPi fn,itoecin ciwhh fncseit irtrhdyoe re,srcsropu snguiac npunoiettrir of eehortytycr d.pntroiouc hisT si teh mase ayw ti ceassu rpshoyd eatfisl ni unobrn ebisba nda palictsa aamnie in iclsek lcl,e ce.t

gainsgutsglory  I get Parvo has tropism for RBC precursors, but wouldn’t it take 120 days to manifest? +  
keycompany  RBCs don’t just spill out of the bone marrow every 4 months on the dot. Erythropoesis is a constant process. If you get a parvo virus on “Day 1” then the RBCs that were synthesized 120 days before “Day 1” will need to be replaced. They can’t be because of parvovirus. This leads to symptomatic anemia within 5 days because the RBCs that were synthesized 125-120 days before the infection are not being replaced. +16  
drdoom  @gainsgutsglory @keycompany It seems unlikely that “1 week” of illness can explain such a large drop in Hb. It seems more likely that parvo begins to destroy erythroid precursors LONG BEFORE it manifests clinically as “red cheeks, rash, fever,” etc. Might be overkill to do the math, but back-of-the-envelope: 7 days of 120 day lifespan -> represents ~6 percent of RBC mass. Seems unlikely that failure to replenish 6 percent of total RBC mass would result in the Hb drop observed. +  
yotsubato  He can drop from 11 to 10 hgb easily +2  
ls3076  Apologies if this is completely left-field, but I didn't think this was Parvovirus. Parvo would affect face. Notably, patient has fever and THEN rash, which is more indicative of Roseola. Thoughts?? +4  
hyperfukus  @is2076 check my comment to @hello I thought the same thing for a sec too :) +  
hyperfukus  also i think you guys are thinking of hb in adults in this q it says hb is 10g/dL(N=11-15) so it's not relatively insanely low +  
angelaq11  @Is3076 I completely agree with @hyperfukus and I think that thinking of Roseola isn't crazy, but remember that usually with Roseola you get from 3-5 days of high fever, THEN fever is completely gone accompanied by a rash. This question says that the patient has a history of 4 days of rash and 7 days of fever, but never mentioned that the fever subsided before the appearance of the rash. And Roseola is not supposed to present with anemia. +3  
suckitnbme  @Is3076 another point is that malar rash refers to the butterfly rash on the cheeks that is commonly seen in lupus, so the face is NOT spared. +  

submitted by marbledoc(0),
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Wyh wodul uoy sak het aniettp ot iftniyed eth osrp nad nsoc? I ndo’t teg teh phcaoarp h!eer

someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +6  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +4  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +2  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +3  

I put constipation because I thought the medication being described might be CCB: can someone explain why nitrates over CCB?

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance. +4  
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload. +2  
beto  decrease of cardiac preload is another word of Venodilation, so Nitrates primarly venodilators. CCB dilate arteria more than veins +  
zevvyt  also, verapamil is the one that causes constipation. But Verampamil is non-dyhydropiridine, so it works more on the heart than the vessels +2  

how would you rule out C) dysfibrinogenemia? I first guessed APS but switched it because of the PT/PTT thing

suckitnbme  You should be able to rule it out by the normal Thrombin time. Abnormal fibrinogen would have increased PT/PTT but also increased Thrombin time because the entire pathway is compromised by the inability of fibrinogen to be cleaved to functioning fibrin. +4