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Welcome to sugaplum’s page.
Contributor score: 235


Comments ...

 +2  (free120#13)
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rFo ceefrnere A F 2901 gp 361 has a dogo imeag ot ese tshi


 +11  (free120#31)
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aesInc aenyno seel was kiightnn eht sem:a
I aws ctkus weteneb htis nad avtnari of unnnwko gicnniesfa.ic oeew,rHv rinvtaa of nwnounk icgicaesfinn si a eqencsue nto a liegns oeceudltni

nbme4unme  Thank you for explaining, I selected the unknown significance answer as well! +2

 +4  (free120#9)
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siTh suqineto is kginas atuob DJV aanmrgnteeerr cwihh hesanpp ni hte bneo r.owarm Teh esnge rae lla cppdeho pu becueas eht B ecll si ntgyri ot gareteen a euquin nnobiacmiot rof ist ctpoeerr
splemi pe.o.tnsc.c dod idrwong

atephCr 3 fo ohw" het nmimue teymss wokr"s - smeaweo kobo

varunmehru  in the question stem, they are asking about a constant region. VDJ rearrangement is for the variable. It doesn't make sense :( +1
sallz  Both the constant (heavy chains) and the light chains undergo gene rearrangement. The heavy chain undergoes V(D)J random recombinations, while the light chain undergo VJ random recombinations. So gene rearrangement could work for both regions. +5
azibird  The constant region does not undergo recombination. That's why it's called constant. It's just right next to the variable region though, so they get expressed together as one protein. That's why the constant-labeled DNA region is variable length here. +

 +8  (nbme23#45)
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hisT si siiruudloc ubt I oclud nrvee kepe eesht hatrisgt oes emt ym mla:y fi
Ay hec gnarpda eeyrnMt
o eDp uniosc TV tihw a isde *Ho 'oshw( eanms aer sujt )iatniisl cNS
Unecl and taun Rpaeh and sara Couisn bbyaG salywa aernicsmg -NNa-Naa
ie pron nesdmir me fo the orloc ,bleu os usocl seeuuclr

paulkarr  LOL. Achey Granpa Meynert. I'm gonna steal this from you. +
abhishek021196  Achey grandpa Meynert = ACh / Basal Nucleus of Meynert Dope Cousin VT = Dopamine / Ventral tegmentum, SNc Uncle and aunt Raphe and Sara = Serotonin / Raphe nuclei(medulla, pons) Cousin Gabby always screaming NA-NA-NA = GABA / Nucleus Accumbens Norepi = Locus ceruleus. +
llamastep1  Amazing +
mnemonicsfordayz  ACHey GRANDPA MEYNERT TREMBLES in the BASEment; DOPE cousin VT SNaCks DOWNstairs by the kitchen TAP; NANA GABBY ROCKS and ANXIOUSLY cooes...; "NENENENE... NENENENE...NENENE...NENE" to CRYING BLUE-eyed baby ELSIE; aunt SERO and uncle RAPHE DULLY PARK in the DOWNpour. CAPS = relevant info, lowercase = irrelevant. Includes diseases: DOWN, ANXIOUSLY, CRYING, DOWN = anxiety/depression; TREMBLES, TAP, ROCKS, PARK = movement disorder; GRANDPA = Alzheimer's. Note: ELSIE = LC = Locus ceruleus +
mnemonicsfordayz  The extended "NENE" series is just for humor - shorten if you like ;) Also, ANXIOUSLY applies to both NTs in that sentence: GABA and NE. +
castlblack  I use AChoo meynose +

 +10  (nbme23#41)
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syawal remerebm mhet ni eodrr wtih mau,lorf AE=IETISS
dna het two no het EDN era NDC-DAITUO

makinallkindzofgainz  The supraspinatus AB-ducts. The Subscapularis ADDucts +
makinallkindzofgainz  disregard my comment, I misread what you meant +
drzed  How are you supposed to remember which S is which? +1
drschmoctor  @drzed "Supra" = on top, so the 1st S is for supraspinatus. +1
usmleaspirant2020  according to Physeo : INFraspinatus--EXternal rotaTION------INF-ECTION +
destinyschild  wow, sugapulm, that mnemonic is gold. you are gold. +

 +3  (nbme18#44)
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FA 1209 pg 555
cueas fo iobtclmea lkasoisal n inotigmiv eeoomsn hows a liumc,be ioaamklhepy dan aymohoilchepr rea ommnco.
onnia gpa mlufaor Nca-iC+lab(b)r iecnS ew evah ecsivxsee icabbr ehert udtsh'onl be a rglae pag. Nomarl si 1-8.2


 +2  (nbme18#25)
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hmwivop/hw7md7ig4.st4:t1/4.u.enncp/n/wb.bl6 ncommo suesis ni peyt 1 adn eypt 2 ibaicsetd

azibird  That article does not once mention the word diarrhea. +

 +1  (nbme18#15)
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FA 0912 gP 373
iocrnc h isitgsatr musolac afimnmitoaln ineglda ot ythorap

pg32  I would also add that I think they are specifically trying to get us to think of pernicious anemia here, where parietal cells are destroyed/lose their fxn. In that case, ECL cells may hypertrophy to encourage acid secretion because the parietal cells are not responding to their usual signals. All the other answer choices are quite clearly incorrect, and Zollinger-Ellison is a gastrinoma, which causes hypertrophy of the gastric mucosa so that is also wrong. +7

 +1  (nbme18#27)
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FA 0912 gP 102
picroeyslon c saeusc eisronyhntpe dan ohonecxritipty


 +4  (nbme18#40)
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eht reedep eht mamanelo sego eth oresw teh sposnogir

wishmewell  isn't the basement membrane the deepest? +
wishmewell  nvm! lol +1
lilyo  I also picked basement membrane but unlike you I haven't had a "nvm" moment. Help please. +1
mcdumbass  @lilyo Basement membrane is between the epidermis and dermis; beneath the dermis is the subcutaneous tissue +3
blah  I think some people might have picked basement membrane because we're taught once cancer goes through the BM it turns from in situ to invasive. This is correct, but subcutaneous as the others pointed out are deeper so the prognosis is worse (BM + deeper tissue). +1

 +0  (nbme18#45)
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bnb dvoei - titnovinlae adn rnipsfeo.su
veend iradutetln tub lwle ruesefdp = taorapi,nis cusmu p,gul aitcslt.aees his t ssucae hsilocgiypo .itnghsun


 +2  (nbme18#48)
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roslhCeltoe trsee arhldsoye is eneded orf eresresv eorollsceht satonprt,r nto taecarnpic nmysze.e
- I isdems hsit
pmntdmw/nhb7to4i.he0lcp.3nsg291/.w:./b8uw/vi


 +1  (nbme18#13)
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eaHinrp idudnce oytia:bortmehpnco gGI aingats eptallet ofrcat 4
AF 9201 geap 724


 +1  (nbme18#3)
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AF 2910 pg 422 m&;pa bbn vieod
AD at olw eosds d1 etaldsi rneal ee,vslss
dm miue 1b istanog = coiopinrto dna oohtcinrpoc
ghih edoss 1a agstion = cvisrnocotsnotai


 +6  (nbme18#33)
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FA 9201 gp 5-961
X nlkied uusclarm s.phtrdyoy eh T cnache ttah eht mom II-1I si a irecrar si 2/1. YX aolmn(r dnrgapa II-)1 * XaX acrr(rei madrmong -I2)I u Yo wkon tath III1- si a ,maefle so olny ookl ta lhaf, os 12/ ehcna.c
eT h heacnc thta IIIs-'1 amte is a ieracrr is aren oz.re oS ew mkae mhi .morlan Y X nralmo( a)Dd * XXa rer(aicr mmo -1)III inSc e we nwok its a oby uoy loyn kloo at af,lh so the anhcce fo him avgnhi ti si /12.
so 12/ * =21/ 1/4
e heTs era two deeidnetpnn vee,tsn eth ncaceh teh mom si a rcaerir * the canhce eth dik etgs hte fdateecf X.


 +1  (nbme18#47)
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aiytiInlb to flxe ta hte DIP si ecdall sJr"eye gei"fnr

w:twtdwoucht/h7ub/swhywXamsceomaNt?p4v/=..u


 +5  (nbme18#6)
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th4 npegaahrly cphuo ivges reis to uosreipr ht.iyrsaordap
FA 9120 gp 607

riyadh  What he want to know about choice B? +

 +4  (nbme20#21)
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B leseeHn- tCa crhaStc in m-nomenmupioottc - wh.lmcc.utssto/:atpywlhoth/ynal.acottlgtoswrioctpnip/hpmdomhce/e lonelaBt ra sanlheee in cis-eIpdrmoon-mmoum iBylciraa agmsanitooist okLso like kiaops smcarao ie"Df ufs hiernctioupl initatfrle" F A 1029 717

almondbreeze  FA 177 says Kaposi has lymphocytic inflammation whereas Bartonella spp has neutrophilic inflammation. I guess this does not apply when immunocompromised? But doesn't Bartonella usually affect the immunocompromised ppl? +
almondbreeze  Got it after seeing that she's immunocompetent +

 +1  (nbme20#15)
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tnitSehyc idoceen nla,oag sha mldi idoOip feesfct ewnh sued in ghih scartnn.ooetinc neHec nnioatpctois FA 0129 617


 +1  (nbme20#34)
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Teshe lawysa itdrpep me p:u
+ pyolidPias= essropdn ot ewrta ,raeptiovdin olw esumr Na
+ leaCnr=t eprnsods to spvairn,ssoe high mrseu aN
neh rpgi+eoNc = erdsnpos to ,hnngoit anlmor msure Na

lynn  I think serum Na+ only depends on the patient's access to water. FA19 pg 344 says serum osm is high in both and doesn't mention Na specifically. Spent a while double checking for DI, but low serum Na for polydipsia is definitely correct. +
drzed  In general, SIADH or polydipsia will cause HYPOnatremia, and DI (central or nephrogenic) will cause HYPERnatremia, but in the latter--as you stated--water access change the serum Na. +

 +6  (nbme20#26)
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isTh si pplatayren ionntaelcg thyrdoi binnigd lolngubi efidynicec

y"nrexinhdobiig-nT nbulilgo eiyfcencid — hnogTiyinbienr-xd gnioblul T)B(G cedfnyecii si ahrcrcedtaezi by wol umser oatlt 4T utb nolrma refe T4 nad TS;H het adgsniois si domcinefr by rgsnumiea BTG scntn.ocrteoain eehsT tfnsnia hvea lnmroa dtrhoiy oncfntui dna od ton reuieqr tt.ertean"m - 'nodatac* uttpe difn ni F,A yebam ti si in treeh ewreeso?hm

hhsuperhigh  The only thing I can relate to this is FA P331 " TBG in pregnancy, OCP use (estrogen increases TBG) increases total T3/T4", so here is the opposite situation, which TBG decreases, and total T3/T4 decreases... +4
jawnmeechell  Goljan talks about this (around 33 mins into his endocrine lecture) in relation to increased androgens causing decreased TBG +2

 +2  (nbme23#41)
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AF 9102 pg 216 -lrsiei cpdnoEvexm urlamocn heptleimui

hopsalong  I use barrett's esophagus to remember these questions. Remember barrett's esophagus is squamous to columnar metaplasia -> this happens because of increased acid in the esophagus. What this means is that columnar cells are better for dealing with acid/internal fluids, and are a better cell type. Squamous is a better cell type for dealing with outside irritants. This means the vagina will be lined with squamous cells normally, and the cervical canal will be lined with columnar epithelium. +8

 +6  (nbme23#12)
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nimpenlpaaopnerolhy is an palah atsoign thta stilaetsum lurreaht omhtos cumles .rtncaonotic - mrfo etpao,dut ovrhee,w ti olsa ayss ti is ont necmedmeodr ttaenmter yearmon

ugalaxy  α1 stimulation (via α1 agonist) constricts the bladder sphincter thereby, preventing sudden bouts of micturition during coughing/sneezing (abdominal stress). +5
sammyj98  I thought that B3 stimulation stopped urination +5
adong  @sammyj98 B3 would facilitate bladder relaxation +
hvancampen  @sammyj98- were you thinking of oxybutynin? (thats what I thought of!) According to FA, its used for urge incontinence not stress. +1
drzed  Nah he/she's talking about Beta-3 receptors which are Gs coupled. Gs increases cAMP thus it would cause smooth muscle relaxation -> bladder relaxation! +
donttrustmyanswers  From Mayo: "There are no approved medications to specifically treat stress incontinence in the United States. The antidepressant duloxetine (Cymbalta) is used for the treatment of stress incontinence in Europe, however." +1
nreid4  @hvancampen oxybutynin is an M3 muscarinic antagonist, not B3. +
alienfever  I thought about B3 agonist as well and got this wrong. I think maybe B3 agonist can be used for bladder (URGENCY incontinence) where the main issue is detrusor over reactivity. In STRESS incontinence however the problem has nothing to do with detrusor, so we use α1 agonist to constrict the sphincter. +




Subcomments ...

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Below teh ettndea ei,nl alna canrce aagdrein si fserluicipa ui.ginaln Avebo het eaetndt nlei, rpsiuroe tclera tehn( lic.)ia

sugaplum  above the dentate line superior rectal drains into inferior mesenteric then goes into the portal system http://www.surgicalcore.org/popup/420229 +  
sugaplum  my mistake, the question is asking lymphatic drainage not venous +1  


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eoBlw the eatnedt lei,n lana crneca deiaargn si uipielafsrc i.nnlgiua vboAe teh ntetade ne,li rirpoeus eatlcr h(ten i)il.ca

sugaplum  above the dentate line superior rectal drains into inferior mesenteric then goes into the portal system http://www.surgicalcore.org/popup/420229 +  
sugaplum  my mistake, the question is asking lymphatic drainage not venous +1  


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ticcaroN esu rof cyueatl ifapuln iodtsocinn si hobt oealnbaers nad itonmatpr. mre-oSrtth use l(madiymetie uosgsa)lr-ictp dose nto ldae to t-orlmgne depcnenede (ro os ppleeo aveh g)h…uoht.t nAd esy, udrsg ddicsat slodhu osla iereecv tsaicnorc to orcolnt np.ia

drdoom  prefer “patients with hx of substance abuse” over more conveniently typed but less redemptive “drug addict” +8  
sugaplum  I don't see why switching her to oral pain meds when she is ready would be incorrect. Clearly she is worried about being on the pain meds, I feel making a proclamation that she has a low risk of addiction would be profiling just because she doesn't have a history. The opioid epidemic also affects people who didn't have a previous history of drug abuse. Just a thought, not trying to push any buttons. Maybe I am thinking to hard about this, but I don't see the clear A vs B line for this question. +30  
nbme4unme  @sugaplum I thought the exact same thing as you and chose the acetaminophen answer accordingly. I maintain that I am correct, my score be damned! +5  
sushizuka  I had a similar question on UW and the explanation stated that the correct answer choice was the only one that addressed the patient's concern and answered her question. The rest were just alternative treatments, so they were incorrect. But I too answered with oral pain meds. +2  
angelaq11  couldn't agree more with you all. I chose acetaminophen because opioid abuse is NO joke. The crisis is still going strong because of answers like this... +1  
houseppary  I ruled out oral acetaminophen because they described in great detail the severity of her injuries, and indicated that she wasn't even fully conscious/aware when she asked this question about opioids. Rather than expose her to more pain, and possibly worsen her long-term pain prognosis, by switching to acetaminophen too early, in this case it makes sense to keep her comfortable because she's very seriously injured and not even fully lucid. It's kind to reassure her in this case. +1  
anastomoses  I appreciate all of the passion for the opioid crisis, and the wording of the answer is definitely not ideal. However, PAIN is also very real, and there is no way acetaminophen alone would cut it in a case like this, not "as soon as she can take medications orally." Maybe I'm lucky to have 6 months in clinicals before STEP or had a mom who just went through urgent spine surgery for breast cancer mets, but there is a time and place for opioids and this is clearly one of them. Thank you for coming to my ted talk. +2  
llamastep1  I agree with anastomoses, cmon guys have you ever had serious pain? oral acetaminophen is NOT enough for that type of pain. +1  
sora  I r/o oral acetaminophen b/c she's post-op for major GI surgeries so you might want to avoid PO meds for a while +  
melchior  As argument against the oral acetaminophen answer choice, it says "switch the patient to oral acetaminophen boldas soon as she can take the medication orallybold" This means you're just waiting for her swallowing inability from the facial fracture surgery to come back, which might not have much to do with her pain, and so it seems somewhat arbitrary. +  
drpee  Maybe logically/clinically A is true, but this seems like a "patient communication" question to me and I could NEVER imagine A being a good way to phrase this point IRL. +1  


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oNte atth eht etqsniuo is tno asgkin hawt llsec htgif UsIR. eTh oqseutin asks atwh bal nfigind dwuol be sttcisonen hiwt ddeasrece mnmiue ttviyiac (dan tshu hte yoln hceoci htta ehmatcs ed“aedsce”r tihw an mneium llce is hte ebts snw.ar)e

sugaplum  So I read Lymphocyte as leukocyte (because cortisol probably) so that is what I put. but cortisol does increase levels of neutrophils floating around in the blood right, I was going for stress demarg. Can't tell if i am thinking too hard about this. +  


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iLegyd lcles amek tsne.oteoerts eygLid cell osumrt an’ret saylwa laihplogsocyi vaeci,t but ehtos atht aer can uaesc i.iilznuaoanctms Gnarusaol clle st,omur no eth roteh d,han issoetmme recoupd etoersgn ic(hhw anc edal to opouriccse ubertpy in gynuo srlgi tbu etriowshe may eb )cco.lut eTtraasmo era lddsobla htat lcyaplyit ehav at,f ,rhia tte,he .etc shTomeca liwl not eb no ryou e.tst iOavarn ioccandri si hghyli ilklyenu ot wsho pu on uoyr s,tet ubt fi ti did, it dwolu ielylk prstnee iwht a cssicla odncriica m.nyedsro

sugaplum  FA 2019 page 632 +  
divakhan  because................"Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" NBME 24 -#13 Qs explanations/comments on this website, has led me to choose this answer! :D +5  


submitted by sympathetikey(980),
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Tsth'a a wne .no...e

ts.gwrenwp.eAsdyit:p_isoeck/eirn/ie/k/slaphoci

sympathetikey  Makes total sense looking back. Just didn't know that was a thing :) +14  
sugaplum  Fun fact: Meredith from Grey's anatomy got her idea for Mini livers from a patient who presented with an accessory spleen.... and who said watching TV doesn't count as studying +18  
123ojm  have gotten at least 10+ NBME or Uworld questions correct because of grey's anatomy +2  
rongloz  LOL got this right because of Grey's anatomy too +  
chediakhigashi  ...today years old +  


submitted by step420(33),
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hisT si maeirnull esesa.ign Nmlrao seavior tub eatsnb uetrsu.

endochondral   why not androgen insensitivity? +  
shaeking  I was wondering the same thing because doesn't androgen insensitivity also have normal female secondary characteristics. Was it the levels of hormones because she doesn't have abnormally high testosterone? +1  
swb  Androgen insensitivity has the same presentation and symptoms. What's the clue that it is mullerian agenesis instead ? +11  
sugaplum  Testosterone would be high if it was androgen insensitivity FA 2019 Pg 625 +12  
charcot_bouchard  Testo would be high in AIS. in AIS pubic hair, axillary hair doesnt devlop because of androgen insensitivity. both have normal breast dev and primary amenorrhea +1  
dickass  This is not androgen insensitivity because she has perfectly normal Estradiol, which means she has perfectly normal ovaries. She also has regular female levels of testosterone. +4  
rockodude  thank you @dickass +  


submitted by hayayah(990),
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Mtos rnireoisctt zyneems ndib reoaipdnl.ms

So ohbt CGC5G' ro '3GCGC olduw vaeh nbee bcepletaca ni tsih i.resocan

meningitis  Yes, correct. The 5'GGCC option could cause some confusion. +  
guillo12  I really don't understand the question nor the answer. Can someone explain it for dummies like me? +6  
whossayin  yes please.. I'm with guillo12 on this +  
sugaplum  @guillo12 @whossayin questions says you've created a new cut site, 1. look at the region on the sick vs healthy. The C to G is the change 2. Write out the sick "CCGG" from 5'3'- you could write out the whole thing, but the answer only has 4 letters, so being lazy here 3. write under it, its complement, the dna base pair. So "GGCC" 4. remember both strands are going in opposite directions when you write them out on top of each other. 5. So the bottom strand actually reads 5' CCGG 3' so that is the answer I hope that clears it up +33  
shirafune  To add to the palindrome part, many restriction endonucleases actually function as dimers. Each individual subunit usually has a nickase, so to create a double-stranded break in DNA, they must bind a palindrome so that each enzymatic domain creates a single-stranded break (thus a double-stranded break). +1  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +1  
alimd  Why do we start from CCGG? Why not CGGG or TACC? +1  
ssbhatti  I think its due to the palindrome requirement? +  
bbr  Maybe I'm missing a part here, but the substrate that the enzyme will bind to will be the DNA. I went with the line that was from the questions stem, as it is the mtuated DNA will be recognized by the restriction enzyme. I didnt see the need to convert it into base pairing. Let me know what you guys think. +1  
uloveboobs  @bbr I agree. I'm definitely not an expert in these lab tests, but the question asks "substrate specificity." I was thinking that it would recognize the abnormal DNA; nothing to do with RNA. I didn't know about the palindromic preference of restriction enzymes, but I don't think there's any need to figure out base-pairing and whatnot here. (At least for this question it didn't work out that way!) +  
spaceboy98  sugaplum, I'd give you an award if this was Reddit +2  


submitted by sympathetikey(980),
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choiCe .A wodul ehva eenb orctrce fi iths tpetian aws mmrimipooedso.umcn Per Ftirs id,A I"f 4CD lt10,;0& dBaiginsano.rn.tl:.leF tlupiorNiceh mailn.atfmnoI

v,Heower as isht nettpai sah a netemtopc umnime ss,mety bzuz wdors ear elltseta nirgtneicoz rolansgamu.

yotsubato  Everyones choice A is different. +  
sugaplum  they mean- Diffuse neutrophil infiltration +1  
macrohphage95  what does stellate necrotizng granuloma means ? +1  
krisgsxr600  always with the details! losing dumb points :( +1  
futuredoc12345  @sympathetikey Doesn't the biopsy finding vary with the biopsy location: Lymph nodes have stellate granulomas and Bacillary Angiomatosis (skin lesion) has neutrophilic inflammation. What do you think? +  
chextra  @sympathetikey Pathoma chapter 2 says cat scratch disease forms non-caseating granulomas +1  
almondbreeze  @ chextra Same with FA 2019 pg. 218 +1  
almondbreeze  Sketchy micro: Immunocompetent: regional LN in axilla in one arm (like our pt here) Immunocompromised: bacillary angiomatsis is transmitted by cat scratches +  


submitted by strugglebus(154),
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Asl,o ckeeMsl dlouw heva resdcbie oheiceamhtza or ieufalr to sasp emimuonc

sugaplum  I believe failure to pass meconium is Hischsprung's Meckels don't present within the first few days of life, so meconium wouldn't be a factor FA 2019 378 +1  


submitted by stepbystep(1),
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soed msoe ndmi aeinlixgnp yhw thsi i'snt a atre ni teh csaciti nreev?

sugaplum  It is a very thick nerve, so I think it is hard to tear without physically cutting it. Also if it tore you would have tibial and common fibular nerve symptoms as well. You would see sensory numbness and tingling along the dermatome also the mechanism of injury is focused on spine so a disc rupture is more likely +1  
zevvyt  I got this question wrong but I really like because it helped me get past a confusion I hadon this subject. If it were a tear, you'd see the loss of motor function that sugaplum was taling about(FA 444 2019). But if it's a herniation, like in this case, you see Radiculopathy/Sciatica symptoms that are on 446. +2  


submitted by yotsubato(806),
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Tshi tesnqiou si slbihtul. heT waonm wldou sotm llkiye eb deianvcact ot pteSr ,npomue pilelyeasc fi hse ahd a spteelymno.c

E cloi si sloa an tnsdlacaeepu cmaetubir atht useacs pmo,nieuan os tath is reom ellyki .OIM

sugaplum  I agree with you, only possible logic for their answer: the qualifier asplenic makes the "ShIN" pathogens more likely, even though Ecoli can cause gram negative sepsis and DIC. FA 2019 pg 127 Also it says s pneumo causes sepsis specifically in asplenic patients Pg 136 +1  
lmfaoayeitslit  To be honest, the only reason I got this right (because I really was thinking E.Coli as well), is that I ended up remembering the MOPS part of the Sketchy, and I couldn't remember if he said that it was the number 1 cause of all of them or not, and ended up clicking it. It's pretty shitty they don't offer explanations for these. +  
merpaperple  I thought this too but it seems like Strep pneumo is just more specifically associated with infection in asplenic/sickle cell patients than E. Coli is. Just one of those classic associations. There's a sickle in the Sketchy Strep pneumo sketch, vs. no sickle in the E.Coli sketch. +  
drzed  E. coli causes pneumonia by aspiration, for which this patient had no risk factors. For USMLE, if they don't say the patient is vaccinated, you can assume they are NOT. Just because she has a history of splenectomy following trauma does NOT mean she had to been vaccinated--don't fill in the history for the patient, only use the information they give you. +  
vivijujubebe  also DIC more often seen with G- bacteria right???? That's why I chose E.coli instead of S.pneumonia +  


submitted by whossayin(18),
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yhw ac'tn agafcotiionnr"i tcefed ni 3T nad T"4 eb teh ?ewnsra

sugaplum  I think if it was organification defect you wouldn't have a normal T4 level in the serum. +10  
divya  because there would be an overall decrease in serum T3, T4 and increase in serum TSH levels. +  


submitted by hayayah(990),
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Ltlite ifgner = nurla ne.evr

C-81T rae hte toosr of teh raunl ,eervn iwhhc si a bnhrca fo teh adielm dcro. Teh nlrua enver is ton uodfn ni eth lpacar tnnuel th(e limade renev s.i)

aUnlr .n amaedg anc dale ot ssol fo tsriw flxineo nad aidcuo,dtn oxfneil fo dlmeia n,sfeirg dionaucbt dan odacitund fo ifersng sirineo,s()te snaoict of iamdel 2 liabmlcru lsesum.c ssLo of neatssnio eovr emdlai 1 1/2 ,nfsergi iclngidun epothrhnay emnn.iece

sugaplum  Also to add: since it is a bilateral sx it is more likely to be coming from the spinal cord then from equal compression of ulnar nerve (in guyons canal) on both sides. unless she is a cyclist +20  
thefoggymist  shouldn't the other nerves of the same roots be affected? +  
thefoggymist  shouldn't the other nerves of the same roots be affected? +  
charcot_bouchard  Not really. In klumpeke paralysis ulnar nerve s/s dominates (Almost same cause) +  


submitted by hayayah(990),
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Wiht iohrccn imtnv,oig uoy seol corleeytselt nad a lot of aid.c It gergtsir tmlaicoeb akosllasi iwchh si wyh lal the rmeus lsaevu rae low ro( on the wlero dne of the monlra nerg)a epxect for rabatbneio.c

ergogenic22  decreased K+ (from increased RAAS due to volume loss) and decreased Cl- (loss of HCl from the stomach), Alkalosis from loss of HCl and thus high bicarb. For this reason high to mid range K is wrong +3  
sbryant6  Wouldn't increased RAAS lead to increased Na+? The answer shows decreased Na+. +3  
sbryant6  Also, remember Bulimia Nervosa is associated with hypokalemia. +1  
sugaplum  so the range they gave for K is 3-6? so 3.2 is WNL then? or are we just operating on "it is on the lower end of normal in peds" +2  
dbg  sodium levels in pyloric stenosis vary, nothing really classic, can be high as in this case simply due to hydration, can low in other cases if aldosterone managed to reverse that to the other extreme +  


submitted by namira(26),
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bseolsiP tlpxnniaoea:

If eth tp is kignat a aziediht whh(ci is K e,tiedg)lnp it ighmt vaeh osal bnee gvnie tiwh a K ipanrsg dgur such as nl.srocotenipia

iaSnteornoplci sha rdogicennciool eftefsc suhc as gnocyitsmaea nda aa.rcletarhgo

sugaplum  I think you could only make this assumption if they said "patient is on standard htn tx" but since they gave the name hctz, would not be fair to assume they are also taking spirinolactone. I went with process of elimination on this one. Even checked access medicine's drug adverse effect profile...galactorrhea not listed for hctz +2  


submitted by hayayah(990),
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Moltahen si xitoc by two ecnmass:mih

isF,rt omtahnle acn be tafla edu ot tsi SNC sdeaseptrn erspeoirpt ni hte saem emnnar sa neohalt spngoii.no

c,odnSe ni a coeprss of tt,noixioac it si toelmizdabe ot mrifco caid iva hlefrdomdaey ni a cposesr teindiait yb the yemenz loclaoh raydhseenogde ni hte l.irev Maletnoh is venotecrd to ayfordhedelm via llhcooa hedysonegdrae AH)D( nad myoedadlrhfe si erctdevno to mcriof daci a)ortfem( iav hdalyede deeydsnearohg D)(H.AL

Fetamor si itxco aubseec it ithnibsi cloiarothmnid etcrmhocyo c de,ixosa snaicgu aiyoxph ta eht lrclalue lev,le dan tilmabcoe adoi,icss nmago a aevrtyi of ehotr beloimtca ndasuet.icbsr

sugaplum  Good pictograph comparing methanol, alcohol, and ethylene glycol. https://wikem.org/wiki/File:Toxic_alcohol_ingestion.JPG +6  


submitted by thomas(-1),
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senwrA is s.yAotcetr tatineP ash litmglbaasoo reutmlmoi.f Alhoguht miemnagonsi may cocru ta iive,osnxcet engmisaniom rae ngneib dna eofnt ysaitmtamp.co yheT aym eusac ah/ rzieuses, but udowl eb kniuleyl ot ceusa hdaet iw/n m6 of enots fo a/h. hTe ezis fo mrotu adn crueso of snlslei is nsniocttse itwh teh ouesrc of BMG

masonkingcobra  Above is obviously incorrect because the answer is Meningeal lol. Here is a link to a good picture: http://neuropathology-web.org/chapter7/chapter7fMiscellaneous.html +16  
kernicterusthefrog  Obviously thomas is disagreeing with the presentation of the question, and I agreed with him! This absolutely sounds like GBM, with rapid onset leading to death, and the symptoms. The question stem leads you to GBM, and the gross image to meningioma (I guess). +2  
kernicterusthefrog  Furthermore, where are the meninges on the gross image form which this (meningioma) grew?! It should at least show the tissue from whence it came! +1  
nala_ula  Had the same problem, got confused since it appeared that the growth was malignant :( +  
sugaplum  FA 2019 pg 514, also agree with everyone. weird presentation. Glios are malignant death within 1 year, meningioma are often asymptomatic or have focal signs. just a gross pathology question at this point +  
garima  ı think she died bc of pressure or something guys, its obviously round shaped benign lesion, its also extra axial not like GBM. she had this maybe years before death +2  


submitted by celeste(68),
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iTsh ndssuo iekl niFcano me.synord The ilxpoamr balutru liplaihete escll aevh a rdah ietm ibenoabrsrg fleirtt,a os l'uyol ese a ssol fo ppeahots,h maion dica,s b,arniaetbco and oleugcs.

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +3  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +1  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +1  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +  


submitted by sympathetikey(980),
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aHdr to see edu ot orop pctireu lyqaiu,t tub asdbe no hwta I olduc ee,s ti esesm eikl a enpnatosuso hueopmroxtna ot em es(abd on eht alck of lnug kgmiran on eht etlf pdormaec to teh rthgi e)ids.

re,rfheoTe scien teh unlg si ,edaltefd lla uoy dluwo ahve in teh lfte side fo teh noep cyatvi, whchi wulod make eth fetl sedi .rensteyaonhsrp

sugaplum  FA 2019 pg667 +7  


submitted by lfsuarez(132),
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eTh inatetp is rpsdbeiecr aSlidfinel hwhic acsude cndsierea GcPM evlels aer heoreetfr STMHOO CMLEUS ainlr.atxoe In siht case yuo wluod twan to adeilvatso hte eedp retyra to neiearsc dlboo wolf tnio the roaorcp n.arsveoac

sugaplum  aka cavernous artery, that is what I was looking for. Did not realize it was also called the deep artery +5  


submitted by mcl(517),
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atinetP wthi eatbrlila raeln ayerrt rbuits nda eiorsepnhnyt wlil rfo sreu ahve viactntaio of RSA tmssye nda heorerfte iersecna ni insegntiona.

hotuhAgl chmhoopotacymoer dan ocneetnqsu tvdleeea ntmosalihccaee nac ceinreas ldobo erps,ruse ptsosymm rae ycallypti cpdoisei nad ranle brsuit rae otn ykllie ot eb aed.hr dvteEela ellsve of esonritno nca lsoa acuse it,ehypsonren but ew doluw alos texpec ot see ilgfsuhn; soal, eerht is ntingoh ni hte setm ot ideincta piatent si iangtk RSSIs ro tnsgihemo esle thta codul pdiseosrpe reh ot vedleaet lesvle of rsnoiento. adeEevtl veslle of yrihtod omhrneo loucd oasl eigv neapitt oitneep,rhysn tbu we would soal petxce torhe nsgis of yrieyopithshdrm rt,o(esrm ehwtig os,ls ).ec.t

I asw a illtet uncdeofs if EOP dowul eb teveelda -- fi hrete si iosntsse fo aerln ieasertr as( daiicednt by the triusb) eht kdnesiy cuold saol teetcd sthi sa xihapoy nad arpm up ooupcdrint fo P.OE ewoHrv,e I ndeed pu ngoig thiw stonnniegia escin it meesed reom o"cer"ncte to em that ARS douwl be .pu seoD yoeann onkw wyh sit' otn PE?O

brise  Wouldn't that be more long term? +2  
sugaplum  I think Epo would indicate Rcc or renal failure, she seems like she has "just" refractory HTN, and no other sx to indicate anemia. +  
davidw  She has Fibromuscular dysplasia which should be in your differential for a young female with hypertension ( along with Conns syndrome and pheochromocytoma). it typically causes stenosis and aneurism formation of the renal arteries leading to elevated renin. +2  


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hTe aptitne hsa TAN nerydsoac to areln hsiimaec. uDe ot rltaubu ci,soerns het ntpetai wlli hvae na etveaeld .FeNa The pttsane'i urein ilwl osal eb ul,etdi tbu shit lwli eb fecetredl yb eht lwo uienr o,loamltsiy otn teh FeNa

mousie  Hypotension can also cause pre renal azotemia with a FENa <1%.... How do you know this is ischemic ATN and not hypotension induced Prerenal Azotemia? +7  
sympathetikey  I had the same thought as you @mousie, but I think "azotemia" and low urine output push it more towards ATN (looking back; I got it wrong too). Plus, the initially MVC / muscle damage probably caused some tubule injury by itself. +2  
ajo  This might help clarify why the pt. has ATN rather than pre renal azotemia. The question did mention, though subtly, that the bleeding was controlled. That most likely indicates that his hypovolemia has been corrected. Developing azotemia 24 hrs after correction of hypovolemia is more suggestive of ATN (since he doesn't have hypovolemia anymore). I hope that helps and feel free to correct me, if I am wrong. +25  
ajo  In addition to my earlier comment, I just noticed the question also explicitly mentioned that he was fully volume restored. Which is consistent with my earlier assumption! +13  
gh889  Although initially, hypotension causes prerenal azotemia, the volume correction pushes you away from prerenal azotemia. but they want you to remember that in hypovolemia, the kidneys are also becoming ischemic, and so development of azotemia 24 hours later is more indicative of intrarenal azotemia due to ATN +  
sugaplum  for anyone who wants to see it: FA 2019 pg591 +1  
divya  i'm confused about one thing. if the tubules aren't working like they should, the bun:cr ratio falls right? doesn't that essentially mean azotemia reduces too? +  
osler_weber_rendu  Lets all take a moment to admire how shit this question is "Bp 90/60.""Repeated episodes of hypotension in the OR" and still the answer is ATN +4  
donttrustmyanswers  @osler_wever_rendu ATN can be caused by ischemia. +1  


submitted by shaydawn88(8),
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sI it noa-ravtlaierl natsaeustdr sacebeu itsh ptniate hgimt vaeh HF td/ .a ibf nda tfle iatlra enamg-&nl;rgeett icn yrottchadsi gr&p-uee;rsst euatardtsn urllpae oieufn?fs

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