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Welcome to sympathetikey’s page.
Contributor score: 1253


Comments ...

 +8  (nbme21#26)
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hTe wohle "scpki ta het eau.ecssls.ino. mseo e,ngeid"lb dmea me nkhti rsiPioas.s hSldou haev goen itwh iAnctic siestraoK ebsad no teh taepnti hsyorti (otls of uns sxepe)o.ru

nccAiti Kseistoar

lnmegPatnria losnsei dusace by sun urep.seox Sllam, uog,rh ytusteamhroe or wsrhnobi puealsp ae. sqlroup Rkis of muuassqo lelc cmroaanci si aopnooiprtlr to gredee of telaleiphi .saslpdyai

thisisfine   Same - the bleeding thing pushed me over to psoriasis as well. Oops. +5
temmy  the distribution of the other lesions, forearm, face, ear, scalp..is not characteristic for psoriasis. +6
hyperfukus  the scalp and ear are actually very common for psoriasis IRL the key is more of the fact that its in areas with UV exposure...actually UV Therapy is found to be helpful in treating some pts w/Psoriasis. Lastly the appearance and lots of things bleed if they were trying to go for auspitz sign it would have tiny dots of bright red blood with slightly touching it +4
hyperfukus  oh last thing psoriasis itches! they said no itching +4
drzed  Those locations may be common IRL, but on step 1, if they want you to think psoriasis, the illness script is going to be someone in their 30s (autoimmune age) with symmetric cutaneous plaques that have a silvery scale on the extensor surfaces. In this case, the age and non-classic description (location, type of lesion) made me steer away from psoriasis. +1

 +24  (nbme21#4)
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• ePr toPoclor - nyOl dileucn aitnspet in eht rtuslse who lledofwo hte cooroptl

• As teaterd - Daat ,wsei only ttear het ustbesjc sa hety rewe edretat ex( - fi etprxeeanmli nttaepi esdo ahtw the orcnlot tansiept rea pdspeuos to ,od veom thta eptilrnmeaxe tetnpia ot het oolnrct porgu

• Ienntiont to ttera - uIndelc all ineasttp ni eht sogupr etyh eerw irgyanioll orezidmnad ot


 +1  (nbme21#4)
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• erP ooocPtrl - nOyl ulencid attpeisn in eht uselrst owh owodlfle eht loc•ooprt sA eeadtrt - taDa ,siwe oyln artte the ejcubtss as etyh eewr ertedat ex( - fi eatilexmrnpe etapitn odes htaw teh cotrnlo epitntas aer suspopde ot ,do omve htat xmerlnteeapi etaipnt ot eht rclotno pgu ro

tinneIont to ttare - eIldnuc all peasttni ni eht sgporu eyth ewer lyognliair droindzeam to


 +6  (nbme21#40)
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ooGd c:turiep hCttetsnupo.n-Cgtleoi.hyan:-ecanfsmo//pd-p-uth//ome/tnrSoiesousvta-ontfeapjatsncwn


 +1  (nbme21#34)
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rferIino qloeubi = helps yuo kloo pu ;pm&a .ni

oAl,s tyhe dias loofr of het t,rbio os it amske snsee htta het norfirei uscmesl wluod ag.dadem

sahusema  I know you're right. I was just so uncomfortable picking an answer with "inferior rectus" because damage to the inferior rectus does nothing to explain the clinical findings of impaired upward gaze. Unless the muscle is physically stuck and can't relax or something +5
emmy2k21  Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :( +2
dr_jan_itor  in the last sentence it asks you to assume an "entrapment", so it is actually the inferior rectus which is the cause of the upward gaze palsy. The entrapped muscle is functionally trapped in it's shortened position, thereby not allowing the orbit to gaze upward. +14
chandlerbas  bam! dr_jan_itor just cleaned up that confusion +1

 +3  (nbme18#32)
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senroP pbbryola sah iaerrbItl welBo Sednr.moy deessR,gral it esesm leik rehy'et iytrgn ot rttae ymsmspot itwh an oipoid aiarlir-ndtahe liek dei.mlrepoa

cbreland  "intermittent" made me think IBS as well +

 +4  (nbme18#31)
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ilef-Sleidmt eiadsse nfoet oigwfnllo a el-uflik esllisn eg,( arliv fitnyion)ceM.a be htiehroprydy lerya ni suer,oc oedolfwl by ipsritydohoymh eperannt(m ni 1~5% of .s)esca reyV dreent tiroydh si nse.e

sympathetikey  Short time course & tenderness was a tip for me. +8
rainlad  Aka de Quervain's thyroiditis +

 +4  (nbme18#22)
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A eloy,setcc aslo onkwn sa a dappeoslr dl,debar si a liedamc ciinodtno ni ciwhh a wo'masn dderalb besugl iont reh vi.aagn Some may vhae on ymt.opsms hOrte amy evah tboleur sttragin uairniot,n iaruyrn tiinoc,encenn or nertqfeu .rnuiniato mslopCnacioit yam dneiclu ceurrtnre uiayrrn trtca entnciofsi adn aryinur treoe.nitn

yeisked/ihiesowni.t//atge:wikltpcCo.rp/

cbreland  How would you rule out uterine prolapse? +
baja_blast  With a Uterine Prolapse you would see the uterus move down, into the vagina. With Cystocele you have the finding described in the question; bulge of anterior vaginal wall (which borders the bladder) into the vagina. Here's a pic to help illustrate: https://www.health.harvard.edu/media/content/images/cr/205345.jpg +

 +3  (nbme18#5)
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peAsrap ot be nirbif npsoieitod yrocnesda to braeilcat orsiptnit.ie


 +2  (nbme18#41)
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inualGli rBaer is cl-lTe dedmatie eutsctodnri fo eeltnmdyai o.nasx erenGlyal sntseper htiw a darpi tsone fooinllwg a lvira / tcaelriab sellnsi twih ncsginaed aiylrspsa.


 +3  (nbme18#42)
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• epomP asDeies peTy( )2
    ○ Lakc of - ooysmalsL cerhiganDnb neEmyz α,-(61 c)oasledis
uG    ○ ilBpuud fo ,61 iela
sgkn    ○ rn
eti:ePsaont        § .1 
aregyadmiloC
sympathetikey  *1,4 glucosidase +3

 +7  (nbme18#4)
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eoHints tncleatiyao solawl rof otarxnalei of teh AND so thta inainrotsprtc cna epocrde. All srnat noteciir dcia ecusas het srlgtuoycena ni LAMP to ethrufr tare,um cwhhi uqireesr NAD ncoapitritsnr / sttnroi.lnaa

osler_weber_rendu  The questions asks for response to ATRA. Should that not be decreased transcription to treat the cancer? Which makes methyl transferase (aka methylation) the more likely answer +5
pg32  @osler, no @sympathetikey is correct. ATRA's mechanism in treating APML is to encourage the cells to mature. Maturation would require gene transcription, meaning histone acetylases would be used. +1
nnp  but ATRA is letting transcription of an abnormal protein ( that is 15:17 translocation) +2
lowyield  i believe the mechanism of APML is that the compound protein is ineffective at allowing for maturation of the blasts. giving ATRA allows the blasts to circumnavigate this step, relieving the backup +8

 +4  (nbme24#23)
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eertBt ecutpir - npratth-opdelwhoacur/aNpe.ons:B.e0110c/ujl/wmcse/b8/stgpaw-v/lt2c./wt

yb_26  @at0xibolic, I think you won this competition on finding better picture lol thanks +5
drschmoctor  Those may be better, but this is the BEST. http://bitly.com/98K8eH +7
brotherimodu  god damnit +
jesusisking  Not again (´∀`) +

 +11  (nbme24#37)
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sA per hmPt,aoa

rucasVla" beaiymptielr rocucs at eth lpoia-ryasclpt nevelu"

Tish si wyh, nhew yuo have damee, oyu dulow vahe apgs ni het sv.lneue

j44n  that was my exact reasoning +2

 +4  (nbme24#23)
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I sjut rdtei ot inhkt of hwt'sa eeesladr by eth nalerAd deualMl ie(np.ni)heEpr PMTN is the nlyo ieocch htat dmae s.nese


 +17  (nbme24#38)
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dlouW'ev eebn neic fi tyeh todl you "d2n ieaotcstrnl aepsc" on ftel ro g..h.mrisht

paperbackwriter  It wouldn't have mattered because the murmur is due to increased stroke volume, not anything mechanically wrong with the valves. If they had said A or P then it might have actually caused more confusion (stenosis etc.) +6
cport12  Also an important side note is that with the addition of the placenta, systemic vascular resistance would actually decrease (another organ added in parallel) which should help point you towards an increase in stroke volume. +

 +35  (nbme24#33)
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reyvEnoe hwo tgo iths uiotsenq girht is a opc. ༽ل༼⌐■͟■

dr_ligma  Fkn narcs +2
j44n  whippet_gang +

 +6  (nbme24#49)
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Ptyetr drfsrrtgtw,haaoi btu a good inrdmeer taht oobislmyiefsr can eusca na aedngrel sl.pene

sympathetikey  Due to extramedullary hematopoesis +22
zoggybiscuits  I thought it was spleen but the fact that hematocrit was 24% 4 HOURs later made me think otherwise. It was my understanding that the spleen would bleed you out quick! +
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +1
peqmd  Spleen is most commonly ruptured in blunt trauma so along with myelofibrosis and being kicked on the left side it's just asking to be ruptured +2
limberry  @need_answers the bladder is intraperitoneal, not retro +
limberry  bladder is sub*peritoneal, sorry +

 +5  (nbme24#19)
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wdzozu:Br evcisesex eriatng

lCrtuse hee,ahsacd ni seo,siqtun asylwa oemc with niooutmac tmyossm.p

jsanmiguel415  Also unilateral and periorbital;, can differentiate from migraines because of it's short duration (30 minutes to a few hours vs migraines which is hours to days). Relationship to seasonal/allergies as well +

 +9  (nbme24#24)
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sulcuediP sumnauH

nBolc-ousigdk clei thta esuac eeinstn uuitrrpst ihw todcsaeasi ,rniaotxieosc momylnoc no aclps dan ckne (adeh i),cel dabaitwns alxdian la o(ydb ,liec) ro bpicu nda riopaaen ilersgn bicu(p c)ie.l

estB give awya in iths uitens,oq ofr ,me si teh wieh,"t lgbolrua tracnseorbupe". Losok tsju ikel eht pic in stiFr diA 2109 es(e bwloe.)

hpJpmutgm:h2Di/.oc/n5.iAt./gmrs


 +1  (nbme23#28)
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sKey rwee th:e

r-caGousiul

th-uhPiaoapsr

omniA- iiacaudr

ehTos ludsoh be o-eebsdarbr by eth PC,T os fi ey'reth n,to yepT 2 A.TR

lamhtu  To be even clearer, this sounds like **Fanconi syndrome, which has lead to Type II RTA** +12
yb_26  To be even clearer: Wilson disease => Fanconi syndrome => type II (proximal) RTA +
charcot_bouchard  To be even clearer, you all have been pretty clear +
charcot_bouchard  To be even clearer, you all have been pretty clear +
yng  I don't thin this is Wilson (copper in descemet layer of cornea). This is cystinosis (crystal in the cornea) --> Fanconi Syndrome --> Type II (PCT) RTA. +

 +12  (nbme23#42)
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aCslisc ro.ousihnytmcai

eSe tihs ipc fo eth esticon orf ti ni AF 1029 - 26c2bcndsa7b7ces19f1cg580poxp43m4h5i7e36vopofhe8oe43eo067/th69g6.t.jrs3547b6218.98cbp55t./ef66285t:c82/7o28aa36c


 +17  (nbme23#21)
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dHar to see ude ot poor iecrtpu tylqa,ui tbu aebsd no ahwt I ocdul ,ese it eemss kile a anoostupens erutmpanxooh to em (dseab no hte kcla of ulgn mgikrna on the eftl aodcmerp to eth irhtg d.)sei

ofT,eheerr incse the lung si ltdeade,f all ouy lwduo vahe ni eth tfel eisd of het peno tyv,cia hihwc dlowu aekm het ftel ieds pnnrstreayeo.hs

sugaplum  FA 2019 pg667 +14

 +15  (nbme23#30)
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gtesiBg ulce was ahtt herte swa no meti mefar eg.inv ehTre,orfe sthi sseme to eb a escli" in e"tim ystd,u cihhw senil up ithw rscos eialsctno td.suy

paulkarr  Damn, epi at it again... +4

 +7  (nbme23#17)
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'atsTh a wen ..n.oe.

:ii/ehcoss_si/ttnwkpp/psieeogikrwyar/..Aclnede

sympathetikey  Makes total sense looking back. Just didn't know that was a thing :) +27
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 +22
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 +

 +3  (nbme23#50)
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I ees athw 'rhteey sgiayn ths(i swa my sonedc ocheci) utb at eht msae mite I flee keli a pkcabu of obold duowl vcetiaat eht eeratsoopbrrc nad eusac edradcese mtehpisyact itvatyci to teh SA m&pa; VA onde.

sympathetikey  (choice E) +
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +

 +5  (nbme23#16)
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esDaonheotemx erpspssseu TAHC = tryuiaiPt xeemDeedAho nsaotomna laifs to ssreppsu HTAC = piEtcco HTAC (xe - mallS Cell Lgnu )rneCca

sympathetikey  *ACTH +
meningitis  If im not mistaken, Dexamethosone also fails to suppress ACTH = Adrenal Gland Adenoma +1
therealloureed  I think an adrenal gland tumor would have low/undetectable ACTH? aka no dex suppression +13
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +12

 +8  (nbme23#6)
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enamioSm is teh tmos comonm trualiscte otrmu. 'tsI a gmer clle t.mour lmyoonmC see edrif" gge e."clls

motherfucker2  If it was a woman would be a dysgerminoma. Seminomas have excellent prognosis and highly radiosensitive. MCC testicular tumor +6
drschmoctor  Spunky fun fact: In a normal adult male >1,000 sperm are made per heartbeat. +6

 +15  (nbme23#27)
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yAn time yuo ees dfeix diwe pngtiltis fo 2S, shams ADS.

someduck3  I'm not 100% about this so take it with a grain of salt. But i was confused about why there would be a systolic murmur. I think its b/c prolonged ASD would eventually cause pulmonic stenosis which would present as a systolic murmur. But besides that I super agree with @sympathetikey +
usmlecharserssss  with airpods in 2012 +
paulkarr  Low key was hoping for someone to try and argue this one... +

 +5  (nbme23#21)
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Per FA (pg. 3)66: ciCgneornn tsbrae ce.an.cr.

"poAiamcifilntroeopexreissv/n fo rgtrestosonogepneere / serortepc or ebcrB2- R2(,EH EFaGn pretreoc) is ;mmocon RE ⊝, PR ,⊝ nndeH/aRu E2 ⊝ fomr mero esiae".grsgv

sympathetikey  FA 2019 +4
meningitis  Why others not it: Anticipation: Trinucleotide repeats; CAG (Huntington), CTG (Myotonic dyst), GAA (ataxia telangiectasia), CGG(Fragile X) Chromosomal rearrangement: Many but can think of Trisomy 21, BCR-Abl, etc Imprinting: Prader willi, angelman Loss of heterozygosity: loss of a single parent's contribution to part of its genome. A common occurrence in cancer, it often indicates the presence of tumor suppressor gene in the lost region. +1
kai  trinucleotide repeats are not associated with breast cancer Neither are chromosomal rearrangements BRCA1,2 tumor supressor genes are associated with breast cancer, which is why I chose E, but I guess I should have bought the new First Aid.......... +
charcot_bouchard  GAA is Freidrich Ataxia +4
tulsigabbard  So is the amplification of the receptors unrelated to BRCA 1, 2? I'm still stuck on this as Sketchy states that breast cancer falls under the "two-hit" model. +
tallerthanmymom  @tulsigabbard I think one of the keys here is the question stem; " what is the most likely cause of the OVERexpression in this pts tumor cells?" --> I think that the "2-Hit" model would lead to UNDERexpression of a tumor suppression gene rather than overexpression. Whereas amplification would cause OVERexpression of the HER2/estrogen and progesterone receptors. But, I don't think that amplification would be the answer if they were asking about a triple negative cancer. +1
tallerthanmymom  Also this is on page 632 of FA 2018 for those using that version +
tulsigabbard  @tallerthanmymom - thank you! +
drzed  I can understand why @tulsigabbard dropped out of the race--she's taking step 1 soon LOL +1

 +6  (nbme23#49)
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Auetc ugto ta:etmtrne

  1. DNSAIs
  2. toserdSi
  3. hCiceniolc

I, keli a dmuby, mdsiare o-ezn rof nes-o, ihingknt ti asw tidesor icedpk .atht For yoanne ohw a,cesr nafnozpueylirS cvpietimeytlo ingbithiin ruic daic tinrsboeapro ni teh omrxliap ebultu fo the ki.ndye

:Srocue /ep.ytekiSlz/dg/noi:tpshnirinuiafw/aewop.kir

yb_26  even if it would be steroid in the list, if NSAIDs are contraindicated => we give Colchicine, and if pt can't tolerate Colchicine as well => then we use steroids +4
usmlecharserssss  uptodate - try to avoid steroid therapy in gout , in this case patient has aspirin (NSAID) allergy , so second line is Colchicine , not Allopurinol, which is for chronic management. This case is not RARE and a lot of people sits on Colchicine therapy even if they do not have NSAID problems. Colchicine also First line treatment for Familial Mediterranean Fever, prevent exacerbations. +4

 +1  (nbme23#7)
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aMd at melsfy for iannchgg my rwnaes.

tFulya goilc adem me wreond if tghinit yuor hdae uodlw edcsau aresecind PIC so, ikle a hscingu clu,er you lwduo get neaicdres guVsa vener yittaciv dna eybam ariycbrdaad + hnyeoostin.p tuB I usseg eth ASAR tesyms luodw heva ctaeconurtde ttha nda sdcaue ottcnvciosronais veor 24 su,hro os Homcvyeolip coskh is tyifndeile the tesb o.hccie

sAwlay hlsduo og wtih eht sbouivo snaewr ):

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

 +2  (nbme23#16)
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crueSo: .t/gdan.eiewh/tsprMkoki/nie:ipiwiy/l

"myneli ssdpee teh inrssontmsia of aetrelcicl ieuslsmp edlcla ctiaon tsinopealt nalgo daeyltinem sonxa yb liisnantug het oxan and cgruenid xaanlo bnmeeamr cticcapenaa"

littletreetrunk  I think this makes total sense, but how does it not ALSO stop fast axonal transport? +3
laminin  axonal transport is transport of organelles bidirectionally along the axon in the cytoplasm since myelin is on the outside of the axon demyelination doesn't affect this process. source: https://en.wikipedia.org/wiki/Axonal_transport "Axonal transport, also called axoplasmic transport or axoplasmic flow, is a cellular process responsible for movement of mitochondria, lipids, synaptic vesicles, proteins, and other cell parts to and from a neuron's cell body, through the cytoplasm of its axon." +3
yotsubato  axonal transport is mediated by kinesin and dynein. Microtubule toxins like vincristine block these +3
drdoom  @littletreetrunk "axonal transport" is movement of bulk goods via microtubules (which run from soma to terminus); ions, on the other hand, move in an "electrical wave" that we call an action potential! no axonal (microtubular) transport required! in other words, de-myelination will have no effect on the transport of bulk goods; but it will really mess up how fast "electrical waves" traverse the neuron! +

 +2  (nbme23#25)
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niPa p&;am prterteumae erifsb ofr hte hirtg isde ceom in on het osldra rithg s,die rssco at eth ireaortn iwhte ,rsemcouim nad altvre pu in het itloapScmahin rcat.t

/.ikXsG-cV6Z0W4hto/-a/91tbA39meun-g6ooltllro446/A-XpHs7:jh6I8rAI2euieAAe.9hTssjk28Anm-/j0lygQrgB4tcg.g/to/u3A/eYlgAp4

focus  The diagram here is pretty great, too, for the spinothalamic tract (and it is presented side by side with the dorsal column for comparison): https://opentextbc.ca/anatomyandphysiology/chapter/14-2-central-processing/ +

 +15  (nbme23#32)
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ghuoT oq.suteni

lcRlae atht ainneemMt lhesrame'(zi )gudr si a NADM erocpetR isnttgAnao htta ehpsl evrenpt ciottytixoecx yb kgocBnli 2+aC eytrn. ts'Tha ohw I mrrbeeme stih.


 +4  (nbme23#22)
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eveliBe tsih qstieuno is renrerifg ot icaVserl isaiiLasmeshn.

gabeb71  The give away is the Fever, Pancytopenia, and Hepatosplenomegaly after being bitten by an insect and developing the sore. +14
tallerthanmymom  I got this question directly after the other visceral leishmania question and it made me second guess everything I thought I knew. +6
qball  Don't forget they like to infect macrophages. +

 +5  (nbme23#6)
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kLucy tenddicuo, tbu ogoikln cba,k I veeeilb hatw yeth eewr ggnio fro si htaw hes sloduh heav eneb atieanccvd for ta 6 hmtson of gea (ciesn rhete ear no natraepp .somsp)tym

pHe B iceacnv is luylaus gnvei at ,brith 1 ,mohnt dna 6 mhtosn fo ,aeg os t'si yrttep ionmttarp htat ehs eb ccitenaadv iagntsa ,it senuls hes ardayel has ,it in ichhw esac hse sudloh eb edreatt ot ivdoa rsciihrs.o

ls3076  how can we actually be expected to know vaccination schedules... there must be some other reason the answer is correct +4
cbreland  I don't think we need to know that the vaccination schedules, but that the only other answer with a vaccine was adenovirus. I figured that there would have more symptoms if she had adenovirus (plus didn't fit the typical military recruit/swimmer demographic) +
koko  Why does it have to be something with a vaccine? RSV Is extremely common in babies,shouldn’t screen for that? +

 -3  (nbme23#2)
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enO of hte seid scfftee of idhsylmoahopecpC si usoeslnmreipyops.

eSe lflu tsli fo sdei eestcff :olbew

ls;Mpyonieuoesspr IcnASD;onaiHF n()mmso iyrsedfeif;dao ih ihsyarocitscgmrte nda ardldeb eerpvrcecnen,dat htwi ham(yyfrdn leusls pgruo of d iessnnmba tcoix lsiebeoa)ttm aqd teneadau y.ionrdtha

ninja3232  This is incorrect. Myelosuppression can also refer to the lymphocyte lineage. +5

 +2  (nbme20#49)
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tiDerc Abtgniliuoln = teDcri booCsm tsTe

sceDett aibedstoni unbod ytidecrl to sR.CB iloseHmys somt kyliel ude ot nmsiohgte in teh tsufenrsad dlobo (not seur why it okto 4 sewke whne pTye 2 SH si sdeusppo to eb irkeuqc utb .we)/

ergogenic22  there is a delayed onset hemolytic transfusion reaction which should be evaluated with direct cooms test. https://www.ncbi.nlm.nih.gov/books/NBK448158/ +5
hungrybox  such a dumb question wtf +25
sonichedgehog  takess longer due to slow destruction by RES +
baja_blast  Dang, I didn't know that was the same thing as a direct Coombs test. I guess it makes sense in hindsight. Thanks! +
sars  Theres a UWORLD question with a table displaying the different types of hemolytic reactions. Don't know the question ID. Agree with delayed hemolytic transfusion reaction due to formation of antibodies against donor non ABO antigens. Typically presents as an asymptomatic patient or mild symptoms (jaundice, anemia). Different from an acute hemolytic transfusion reaction, which is against ABO antigens. +1
tomatoesandmoraxella  The Uworld table is in question 17780 +1

 +13  (nbme20#26)
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odGo tiperuc ogihswn hte myaatno fo het tihhg mfro a 2T IRM erseec.ipvtp

0/-77r/0u17071pu00datp5e57n00o97hk5ep9.4ot0ws0y1t/3y.o_54-3o1sda7Bo7l70m9ptjc-c/:g02ln3/99/i80/g786

jcmed  Was so close to picking vastus intermedius +1

 +2  (nbme20#46)
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phrerdsoysonHi

aiinoisinntotD/etld of lnaer vsielp nad yascelc A . lsUyual seaucd yb urryina ctrta suioctrtnbo nae,reg l( ot,enss ervsee BHP, lecntngoia ctibnsostou,r cearvcli ,renacc nyriju to erte,ur ypgcnerna apyeprntla;) thoer l siaecnecsuud orripelteneaort ,orfiibss eercvelituraos fuer.lx Dontiail ocrcsu omxlipar ot eits fo eo orp.mSlhaygut nenreitcai osemcbe deaetevl fi norbtiosuct is atlerailb ro if neaptit ahs na uasyrotcesdbot rtli ndei.yk dLaes ot crnismesopo nad lpobiess thraoyp of larne etxcor nda umldla.e


 +5  (nbme20#14)
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I vbileee hte ospbyi niopictedrs of mal"sl chlsboiplai clels ornmigf mrtou sid"slan is rindibcges hte harpeepirl igdsipanal taht is cassaylllci eens in alBsa ellc mcr.iocana


 +5  (nbme20#27)
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aCse esSire

A rpguo or esrsie fo scea opertrs gnvinoliv itneatsp hwo rwee igven aisrmil rtttmeane. rteposR of esca eirses ylluusa iancnto dleaedti tiarfionnmo obaut eth inidiadluv npsea.itt siTh sduenlci pdchoairgme noantfiroim orf( mlax,eep ,gea r,gneed tehcin ioin)rg adn oniitmnoarf no sois,ading atntr,etme senrespo ot taen,trmte nad foul-wpol teafr enmt.rttae

nI itsh ,uoensqti it oolks lkei hyet tdind' arleyl cofsu on the tteatrenm atrp fo ti but retso,wieh amske neses

sympathetikey  Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/case-series +2
ngman  I think another factor is that in case series studies there is no control group vs case-control, cohort...ect +18
leaf_house  "There is often confusion in designating studies as 'cohort studies' when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ +
fataldose  explanation of one of the wrong options - correlational study A correlational study is a type of research design where a researcher seeks to understand what kind of relationships naturally occurring variables have with one another. In simple terms, correlational research seeks to figure out if two or more variables are related and, if so, in what way. (source - https://study.com/academy/lesson/what-is-a-correlational-study-definition-examples.html ) +
j44n  you dont need a control group in a cross sectional one so how do you differentiate that +

 +17  (nbme20#35)
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As destat leo,wb eth etLf rusc rebiecr wsa edgmaad (see hawt ti suohdl lmyoranl okol ilke ).oeblw siTh icsontna het npiortcicalos ttcar. Siecn eth crcstoaolinpi cttra aduessetc ta hte dluam,el lwobe hte airinmdb snoteic eew'r gniolok a,t you doluw see Clanloaraetrt gR(hi)t pciStas mpHaeseriis

hello  What identifies that a cross-section is medulla vs midbrain vs pons? +4
kernicterusthefrog  @hello I like to pay attention to the Cerebral Aqueduct (diamond/spade shape seen mostly in Midbrain, and transitioning to 4th ventricle in rostral Pons), and then the shape and size of the 4th ventricle as you move down Pons to rostral&middle Medulla, and eventual closing and absence of fluid space at caudal Medulla. +11
hello  @kernicterusthefrog Thank you. +
mbourne  NGL, I thought the right side had the pathology lmao ty +20

 +5  (nbme20#23)
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D4+C clesl tevatcia Blles-c hchiw mofr elloflsic dan eucas gneaermlten fo hpylm osden. f,eerehTro ni an IASD aipt,tne to arelgen teh hplym ensdo, teh +4CD dctonifyuns sumt eb oerls.dev

breis  Yea i get that, but if the patients CD4 was ~35, how in the world did the CD4 count rise enough to stimulate B cell proliferation...? I don't get it +6
namira  The only thing i can think of is that: the cd4 count that is given was taken prior to having started the antiretroviral therapy. Since the question asks about "improved function", maybe its referring to the therapy actually being effective and its managed to increase cd4 count and function so as to be able to contribute to lymph node enlargement due to myco. avium +12
kamilia20  I though it transfer to a lymphoma,OMG +

 +3  (nbme20#16)
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rlpneciiP eynsSro suleucN fo het aleTmnigir is dtcelao ni eth oPsn, sa si eth ortoM mialegTinr eucsluN fo hte np.so hsiT epntrniaseot is yporlabb agnlide orme wthi eht cplreiPin ysroSne suelNuc.


 +2  (nbme20#7)
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nI ioainddt ot PTH = acssoeltto iytctiav = ecsednari c,cuamli ihst respon loudc losa be eitbngiihx msmoptys fo M1E.N


 +16  (nbme20#25)
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tiatMusno in T1ML-T iocldM(ytinalhor nedodec NARt uelncei )1

A mcmnoo iatumont is A3.4G23 Can tseurl ni ptuielml cidnoitrhmoal ifsecciedien and tsiasdocae odrd.srise It si aeiscotsad i:thw

  • ohdntrioMical ceeyhpolyhmatonap
  • cLaitc icssadoi
  • erkk-lSteoi peoediss AMEL)S(

LMSAE is a rare omiltadhoicrn derirsod wonnk ot fftcea amyn prats of eht obdy, ylpleacesi hte onrevus tsysem adn the bai.rn Stomsmyp fo SMLAE nliceud:

  • eunRcrret revsee ehsacahde
  • leusMc ensaeskw )yapomy(ht
  • naeHrgi sols
  • o-Stleikkre seipdeos itwh a sols fo is,enoncsscuso euszir,se nad hotre obmserpl ftecfnagi hte ouersvn tme.ssy

:eurcSo wnpTpiideis1twg/:hkM/iaekL.oTir//t.-

j44n  i just saw that every tissue that was affected had a high 02/aTP requirement and mixed with the lactic acid that meant she wasnt using her electron transport chain so i picked the only answer that had mitochondria in it +1

 +4  (nbme20#43)
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nlalrieMu gsensAei ak:a( yesauMKtknerHyt-su-arRo-riakes ydrenS)om

reepmotUvdndnele of het irMnaulel ymsset lgaiden to netncigloa enebsca fo eth gia.vna syaluUl no ecvxri or streu.u

yaM eernspt as °1 aemeornarh eud( ot a lcka fo uenteri nmp)eoltdeev in ameefsl wthi flylu dpldeeove °2 uxleas sreihsttcirccaa. unnicaFolt seivroa olalw rof ronaml slaxue srticrtcacsahei adn hooenrm lvls.ee


 +5  (nbme20#35)
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lepSen so hegu -- kool lkie iths glri sha 2 erv.sli


 +11  (nbme20#21)
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eihcCo .A dulow aehv bnee eorccrt fi shti pteanti asw imcopsmdonru.emmoi reP stFri iA,d If" 4CD 01t,;&0l t.songl..nBinrliFa:dea iphcNtleuiro fI.ntalmanmoi

,rveHewo as ihts tpantei ash a tceompten imnmue ets,yms bzuz orswd ear etestlal tiocrneigzn aolsuramng.

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 +2
almondbreeze  Sketchy micro: Immunocompetent: regional LN in axilla in one arm (like our pt here) Immunocompromised: bacillary angiomatsis is transmitted by cat scratches +




Subcomments ...

submitted by vi_capsule(13),
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HTN crgyn,eeme miudSo dristpiou.Nrse eknliU irdenhzayla a nleadacb tdirooslava (neiv = aor)eirtl

sympathetikey  Well then, I guess we should just forget about our old pals the Alpha-2 agonists. Good call. I didn't even see that this was hypertensive emergency. Dumb on my part. +  
zup  so yea clonidine would be used for hypertensive urgency, but this guy is over 180 (210) so they have to use something like hydralazine or nitroprusside both will increase cGMP +  
whoissaad  Drugs used to treat HTN emergency: Nitroprusside Labetolol Nicardipine Clevidpine Fenoldapam Clonidine +13  
lola915  Hydralazine actually vasodilates arteries>veins and Nitroprusside vasodilates arteries = veins. Both increase cGMP. +8  


submitted by haliburton(208),
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F2E si tlnrsnoiatala eaoglnoit ftorca 2, cihhw si raesnycse orf inpeort niyhsesst.

sympathetikey  I. Am. So. DUMB. +24  
nala_ula  same :( +2  
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +  


submitted by mcl(579),
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OCPS is acidaostes with baamolrn tpduocrino fo xse sr,doteis duginnlci oyfdtcnsuni fo sornteeg niudtprcoo nad oneerrto.pges ricyonllahC evdeltae eellvs fo teosgner acn ueasc edoenlimtar easiaylhp.pr

//tibM3n7/lprC5/ewtPnv/1.m9wsctlc9io.shp9:i.wmh.cagn/

meningitis  Why isnt it endometriosis? Could someone help me out on this? +1  
meningitis  Sorry, I was confusing with higher risk for endometrial carcinoma. +  
vi_capsule  Estrogen is responsible for cyclical bleeding and pain associated with endometriosis hence progestin is a treatment modality. But estrogen isnt a risk factor for Endometriosis. Rather theres retrograde flow, metaplatic transformation etc theories are responsible for endometriosis. +  
sympathetikey  Tfw you get so thrown off by a picture that you don't read the question properly. +25  
hyperfukus  @meningitis idk if u still care lol but always go back to endometriosis=ectopic endometrial tissue outside of the uterus so you can rule it out since increased estrogen would cause you to have worsened endometriosis or a thicker one but not directly...you can see the clumps of the follicles in the ovaries if you look super close so that along with the presentation takes you to PCOS and anytime you don't have a baby or stay in the proliferative phase(estrogen phase) you get endometrial proliferation-->hyperplasia--->ultimately carcinoma +1  
lovebug  FA 2019, page 631 +  
lovebug  Other answer H)Meigs syndrome : triad of 1) ovarian fibroma, 2) ascites, 3) pleural effusion. “Pulling” sensation in groin. FA 2019, pg 632 +  


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tI sdia ti swa lataf ot lmeas in to,ure nad eth esuoqint sadke abuto ivel robn ngipsff.or niceS hte almse a’retn bineg born in het ritfs aplc,e I isda 05% sealfme dan %0 ames.l

hungrybox  fuck i got baited +30  
jcrll  "live-born offspring" ← baited +21  
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 nosancuck(85),
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Yo sdi B otg NO ALNNTERI FLEEAM SAONGR

Wyh ??a?t!d

eW eb nlooki at omseone hwti an YRS ofrm deer Y Dymr!o ihcee be a Y rciehmo oHemi os ythe be nkmia mseo Tseits itnDeniemr acFotr hcihw I be ures esamk omes inec lil NIAT UEAMLRNLI RATOFC so yed itna ogt ahtt aeFelm lnteaIrn rcTta u onkw twah i be ynsai

Adn icsen mzinwim is ad TLDUFAE heyt itls eb itetng edos syspu islp and esestabr

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by nosancuck(85),
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oY sid B ogt NO RNELITAN FMAEEL NOASRG

Why ?ta!?d?

eW eb oiknol at nmoeose iwth na YRS form eedr Y !y ecrmiDeoh eb a Y cihoemr mieoH so tyeh be maink emos siTest eiinmtDrne aFtorc whchi I eb erus kames mose cnie lil ITNA UIMLENRLA TARFOC so edy inat tog atth eFeaml reItnnal racTt u wkno ahtw i eb yiasn

Adn ecnsi immnwzi si ad LFTADEU hyte istl eb ietgnt edso spsuy slpi adn astberes

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


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st’I tuace colhloa cotnumopins os atfyt anegch moer .lyielk luClrael lelsignw asitcdien cchliooal heatitsip hhciw reiuqrse chcnori ocllhoa tpocnoimnus See( AF 1290 gp 853.) At latse tthas’ eht iolcg I sdeu to cipk fyatt en.cgah

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


submitted by neonem(550),
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reMhionp is a mu pidooi gontsia - eon dresaev ecfetf of sidoipo si tsma ellc danlatenuirog htat is ignpIedneeEdnt-. sleReea fo itnaeishm si iank ot an nlcahpayitca nrcetiao -&;gt- upri,rist e.ct

sympathetikey  Never had heard of that one. Just a good guess. Thanks! +  
yb_26  IgE-independent mast cell degranulation can also be caused by radiocontrast agents, some antibiotics (vancomycin) +6  
temmy  it was a u world question +  
mambaforstep  FA 2019 pg 400 +  
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +  
mannywillsee  i'm in FA 2019 and pg 400 is blood groups and hemolytic diseases of the newborn. I found this info in page 535 +1  
mambaforstep  under mast cells "IgE-independent mast cell degran"! FA 2019 pg 400 +  
mumenrider4ever  Uworld QID 11852 talks about this Also FA 2020 pg. 408 (under mast cells) +  


submitted by drdoom(806),
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5002, nuttesds ... ubt yuo dfni uto urnidg ruoy nlatiii cesrne atth 050 yrleaad ehva eth .aeissed oS, eoktsuirt osthe ope.epl htaT svelae ,0020 nutstsed how do’tn hvae the idaes.se

erOv teh soceru of 1 ayr,e uoy edcrvois 002 dentstus devpeoled eth ne.ftconii Ts:uh

200 wen asesc / 02,00 poelpe owh ’tndid aevh hte dseiase wnhe uoy tsrtaed royu sydut = 01 crtnepe

ic,yTrk kcrtiy NEBM ...

sympathetikey  Ah, I see. Thank you! +  
niboonsh  Im mad at how simple this question actually is +7  
sahusema  Incidence is measured from those AT RISK. People with the disease are not considered to be at risk. So 2500 - 500 = 2000 people at-risk. Of those 2000, within one year 200 develop the disease. So 200/2000 of the at-risk population develop the disease. 20/2000 = 10% = incidence +3  
daddyusmle  fuck im retarded +2  


submitted by hungrybox(968),
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tacyplDsis nevi rea a rcrsrouep ot mnlo.meaa yehT avhe ueg,rlrair claipd"tyss" rser.obd emeRebmr hte "B" ni DABC stdsan for ruigearlr rose.Bdr suevN eamsn om.le

rhOte rswsae:n

  • ichsanasot angrcisni - nkegaDirn fo sink asicoadtes whti pTey II eaetsidb itllumes

  • salba elcl oimrcanca fo sikn - Ryr,eal if vere mz.esattsieas moomlnyC asffcet rpuep pi.l

  • ulbe sevun - e-olluocrBde etyp of omomnc olm.e nBin.eg

  • pmdtgniee rbhcreiose sokriteas - kS"cut n"o enraceapp.a slMyot n.enigb ftAesfc edlor e.pepol

  • Nte(o - oyu lyuusla ese olyn eon. If pmtuleli reechisorb eskraseot aer enes, ti ecdtansii a IG mlnianycga - aka "eTstalrér-eL is)gn
usmleuser007  correction ~ BCC affects the lower lip more than the upper +1  
sympathetikey  Pathoma says upper lip, good sir +25  
hungrybox  Yeah basal cell carcinoma actually affects the upper lip. Counterintuitive because it's "basal" which seems to go along with the lower lip. Here's another source (this website is fucking gold btw): https://step1.medbullets.com/oncology/121593/basal-cell-carcinoma-of-the-skin +4  
pg32  Can anyone explain how we can rule out C or E purely based on the question stem? If we read into the question that we are looking for something related to melanoma, then I get why we can rule out C and E. However, the question simply asks which lesion appears on both sun-exposed and nonsun-exposed areas of the patient's skin. I would say that C, D and E can all occur in that distribution pattern. +2  
paperbackwriter  @pg32 because it specifies "this patient's skin," and the only ones he is more likely to get than the average person because of his family history are dysplastic nevi +2  
teepot123  fa 19 pg 473 +  
rockodude  just remember BS. basal cell upper, squamous cell lower +  


submitted by usmleuser007(370),
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ustJ elezirda ttha leanr lecl ccaamonir 'stin teh ccertor wenars /cb ti inevadd het sonuev ritoiulccna dan ont het rlte.iraa PB yma tno be feefcatd sa uchm. if RCC eerw het wrasen nhte etnh erhet uowld aehv ebne medea sepentr o/adnr ralen TNH.

sympathetikey  Also, just thinking out loud, in the case of RCC, it's the kidney tissue that's dysplastic & moving, so technically the renal artery itself isn't dysplastic, right? +  
paperbackwriter  @usmleuser007 very good point regarding the venous vs arterial circulation that I neglected to consider! +  


submitted by cantaloupe5(72),
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rceRnuter neyikd otsesn huodls ednulci eadhyirsartyhmoprip no uyro dti,rnilaeffe eopluc taht ihwt iaargstmno nad reouy’ knioglo ta EMN .1 osLapmi ear saol escdaoaits hwti ENM 1.

sympathetikey  Yeah, I probably should have went with that. Just got thrown off, since I know that usually the serum calcium levels for someone with Calcium kidney stones is normal. +  
snoochi95  i understand the link to MEN 1, but why are we checking the calcium level? +  
cmun777  I feel like it's important to get a baseline of where the calcium is at for two reasons: 1. if the patient does indeed have MEN 1 it would be good to know if she has high calcium levels and possible Parathyroid etiology 2. You're putting the patient on a PPI which are known to decrease calcium levels and increase risk of osteoporosis for both these possible factors/concerns it would be good to see where calcium is currently at +5  
zevvyt  Couldn't a Pituatary tumor secrete ACTH, causing high cortisol? +2  
lola915  Patient has symptoms of a gastrinoma (Zollinger-Ellison Syndrome)- patients present with diarrhea, epigastric pain, duodenal and jejunal ulcers. Associated with MEN1 syndrome. +  


submitted by haliburton(208),
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klin to arcnoto aragdim

yotsubato  How is that NOT posterior to middle concha? bad question +10  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +3  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +3  


submitted by yo(78),
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tr'eehy gaiknlt aotub a elnoaenrspl snuth repercoud

elmlotas:u/ni4nrd0/.actl5-hacttresnl-mc/teise/stndtnio/.thvshgleprhelypl-anae9

hungrybox  be honest did u know that before looking it up +9  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +23  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +11  


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My thhotgu erspocs wsa ttah omppt-rauts gledneib si llausyu laredet to eht uusr,te nda uchm fo the pvceil acrvesi is ilspepud by baehrncs fo eth nearnlit alici atrer.y

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. +4  
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) +14  
sympathetikey  @tsl - Thank you! +  
step1soon  uworld Qid:11908 +  


submitted by dr.xx(143),
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gmAon het osmt avnrteepl ioglhaometc snmtoibalraei in tteipans htwi leohgrmutacoi eirsdsdro rea eth anemai fo hioncrc dsiesea C,)DA( a lmdi aaenmi ahtt si gealrlyen ctasmmpay,ito nda nroi icneyifcde mna.eai

nI ndceni-iceyfroi aeimn,a hte ITCB ldwuo egrihh ntah 404050– cd/gmL saueecb sostre olwdu eb wlo.

tPneasti tiwh RA lisyccoaanol ehva errucocntn iron dnyieifecc naimae dna D.AC heWn hist ccr,suo the ibelonmogh level usllyua prsod ot eowbl 9.5 /gLd, and teh VMC si slse atnh 80.

t.ehion-cp/wadsogmar.-rn:towtemwnahlef/o/sasitispcsomtcrhtehaf-uoioute/imd-ttanottit

sympathetikey  Got the right answer too, but man, that whole "1 month after starting therapy" almost threw me off. +1  
fkstpashls  all I do is put the wrong answer when I'm between two. Fuck +1  


submitted by yotsubato(968),
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hSe hsa eBadrrn uoirlSe eDsisae gpea 194 fo tsirf dai 1290

sympathetikey  That's a genetic deficiency of GP1b -- not antibody related +8  
alexandramda  In Berard Soulierd you have a Defect in adhesion. decreases GpIb and decreased platelet-to-vWF adhesion. Labs: abnormal ristocetin test, large platelets. +  


submitted by hungrybox(968),
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aka aulpaml of atVre ro hte ttipcanroahapeec dctu

hungrybox  tripped me up cause I didn't know the names :( +13  
sympathetikey  @hungrybox same +9  
angelaq11  omg, same here! I thought, well, I don't know of any duct that connects the pancreas to the liver, so...2nd part of the duodenum it is :'( :'( +7  
alimd  actually Ampulla of Vater is located in the 2nd part of the duodenum. +  
mtkilimanjaro  I think 2nd part of duodenum could be viable if the ampulla was not an option. The ampulla is way more localized/specific to this scenario +  


submitted by drdoom(806),
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tcsociioonatVnsr ino(garwrn of a etu)b wlil csaeu the owfl raet to caeseirn rohtguh htta ,etub wihhc sdeeecrsa adard/iuwarlot u.ersserp ehT eafstr a lufid vmose otuhgrh a ,tbeu hte slse trwudo”a“ coref ti ext.sre (hsTi si nownk sa hte ntirVeu ffctee.)

hungrybox  not seeing how this is relevant +8  
sympathetikey  He's showing how A & B are incorrect @hungrybox +7  
nerdstewiegriffin  what a moron @hungrybox is !! +2  
leaf_house  MCAT flashbacks on this image +1  


submitted by sympathetikey(1253),
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ldiiteS-lmfe ssdeiae ontfe nofoliwgl a -lfuilek slsnlie ge,( alvri ) yM.iieafnnotc eb yroyhpthrdie yaerl in rsu,oce ofdlwoel by pdohoytyrhsimi nm(aerpnet ni %15~ of .sa)esc ryeV rdnete triodyh is .esne

sympathetikey  Short time course & tenderness was a tip for me. +8  
rainlad  Aka de Quervain's thyroiditis +  


submitted by sympathetikey(1253),
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• oPemp sseaeDi yTp(e 2
)    ○ aLck fo - lLsooamys enrchbnaDgi Eemzny 6,-(α1 sdcailsu)eGo
    ○ luiBupd fo ,16 ansg
elik    ○ rs:ane
noettPi        § .1 lCoayredg
mai
sympathetikey  *1,4 glucosidase +3  


submitted by karljeon(111),
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aVmtini E idfeynccei eussac leoimcyht mneiaa, an,hocsttiacsyo ulsemc sasew,enk poteisror oluncm dna enlropcbairlsee tatrc ty.ioenadimlne

karljeon  Can anyone explain why the serum lactate dehydrogenase (LDH) level was elevated? +  
asapdoc  Vitamin E is an antioxidant. Thus a deficiency can cause hemolytic anemia. +5  
sympathetikey  @karljeon Intravascular hemolysis = LDH release from RBCs +2  


submitted by medstruggle(12),
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hyW is teh wenasr rulonn“gaiat its?ues” I ghotthu teafr 14 syad oyu have a flylu rdfome sc.ar

colonelred_  If you go back and look at the image you can see that it was highly vascular which is characteristic of granulation tissue. Scar tissue formation will be closer to 1 month, plus you will see lots of fibrosis on histology. +13  
sympathetikey  It's a bit misleading, for me, since you do see fibrosis intermixed with the granulation tissue, but granulation tissue was a better answer. +2  
haliburton  According to FA 2017: 3-14d: Macrophages, then granulation tissue at margins. 2wk to several months: Contracted scar complete. Dressler syndrome, HF, arrhythmias, true ventricular aneurysm (risk of mural thrombus). i'm getting pretty frustrated with NBME contradictions to FA, and FA omissions of content. this stuff is hard enough to get straight as it is. +1  
yotsubato  Thats cause the NBME exam writers read FA, then make questions not fit in with FA +6  
trichotillomaniac  This fits the timeline laid out in Pathoma! 1-3 wks = granulation tissue with plump fibroblasts, collagen, and blood vessels +10  
alimd  never look at the image in the beginning. They dont want you to success. Most of the time images are made to ditract +1  


submitted by neonem(550),
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eshTe era ougt sc.latrsy I seuspop eht bset ywa to aentirffeited ihts eacs from ugsptdouoe si taht het yactslrs ear srpha a± epehd-saleend dan ton hhordem.i-sbapdo

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. +17  
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. +3  
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 seagull(1405),
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ta BMI 15 otn olyn sah seh vener hda a iprode tbu esh reven dah a lem.a

sympathetikey  You're on fire man lol +  
monkey  How the fuck is it not related to anorexia nervosa is beyond me. +2  
avarkey  the blind vaginal pouch points away from it being anorexia related +1  
j44n  Its actually a man, there's no DHT to to dev the external genitals. +1  
am4140  @monkey - with real anorexia, she wouldn’t necessarily have boobs either. If she’s got boobs she has the nutrition to develop boobs. That was my thought. +  
freckles  the patient is actually what ever gender they want to identify as. If this was a 5 alpha reductase deficiency the patient would have experienced masculinization of external genitalia during puberty when testosterone levels increase significantly. The pt most likely has Androgen Insensitivity Syndrome. +  


submitted by seagull(1405),
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heT snetcmsia fo tish tisquoen emda em mvtoi o.blod

eOn yda a tpaenti wlil okol me in eht seey dan ,sak eerW"h rea setidterpi borkne d"ow?n I llwi ilsem ta hmte and ays, "the tlisnentia acmuos nad ton het eddmuo"nu. 'Thllye selmi akcb adn I'll klwa ywaa dan nhtik fo iths mnmeto as I jmup ofrm eth nid.oww

sympathetikey  Too real. +2  
mcl  how do i upvote multiple times +15  
trichotillomaniac  I made an account solely so I could upvote this. +29  
dragon3  ty for the chuckle +6  
cinnapie  @trichotillomaniac Same +3  
thedeadly96  XD made my day! +  
hardly43  RIP legend @seagull +  
seagull  A legend never die +1  


submitted by m-ice(321),
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eTh tpantei seden emdacil niteottan idi,mlatyeem hihcw salniietem intibngoa a oturc drer,o or nsrraftrgein .rhe A uensr esdo otn veah eth amse nitangir nad ituoqnasfaicil sa a iancy,ipsh os it wdulo eb eropinptapira to ska mhet ot enaimxe het eiatnt.p snikgA hte ashitlpo nphlaica angai lcudo be pr,pteranpaioi dan olduw ekat emor .temi eTher,foer eth tseb itopno naomg shtoe engiv si ot ask eht attienp fi ehs llwi ollwa with her hanusbd pen.sert

sympathetikey  Garbage question. +55  
masonkingcobra  So two men is better than one apparently +28  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gárbágé +4  
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +12  
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39 +9  
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +15  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +25  
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +  
niboonsh  This question is a3othobillah +5  
sunshinesweetheart  this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +5  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +11  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +10  
korahelqadam  All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +  
sars  This is a very fair question. I agree with sunshinesweetheart above. That is all. +  
wrongcareer69  Garbage question +  
alimd  well we should wait for the question "if a man shouts I CANT BREATHE with a police knee on his neck, what is your next step? Ans- wait 8 minutes." +1  


submitted by neonem(550),
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ganiFll no steedrottcuh dh:an oahdsicp is tosm ooncmm noe ot eb ru,cftaerd eatuln is otsm mnocmo to eb codlisa.etd ntauLe ioacotlsdni cna sueca cteau racalp luntne e.odmrysn

hknTi fo the nmoecmni "irhtgSat ieLn To P,kyin eHer esoCm Teh Tb"uhm fro teh snboe of eht ,lpam wdaignr a bafoltol eaphs rtnaigst blwoe eht hbmtu CPM iojnt aandject to eth rd,iusa tehn gonvim ot royu aemldi wit,rs nda tenh acbk ot eth .hmtbu

,hpidcoSa l,nteua ueutrmqti,r i,fmoipsr ea,mtah tatic,epa etiporazd, iptezrm.au eTh eltnau sloko kiel i'st piyrlrosteo odesciltda .hree

sympathetikey  Yep. I didn't even look at the X-ray. +9  
dr.xx  loonies love lunate +2  
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +1  
wes79  i legit have no idea whats going on in that xray lol +9  
nbme4unme  X-ray confused the hell out of me, I was going to put lunate based on Q stem but ended up putting Pisiform because it looks like that's what's messed up in the photo? Should have ignored the picture haha. +1  
nwinkelmann  for @dr.xx, love your mnemonic. I added to it, or at least found an explanation on why it works. "loonies love lunate" and "loonies" are "dislocated" from reality. +3  
niboonsh  Some Lovers Try Positions That They Cant Handle +9  
vsn001  ngl if scaphoid was an option - would've sprung at that real quick -> thanks for teaching me the importance of knowing to look for dislocation vs fracture :D +  
regularstudent  Ahh, the classic "left hand" x-ray but actual fracture of "right hand" NBME tactic +  
sars  I think the x-ray is showing the lunate protruding out of the palmar side. Imagine the situation where you are falling and using your hand to stop the fall. Your lunate will dislocate forward as the rest of the carpal bones recoil back, hence why it protrudes through the palmar side. Thats why it causes an acute carpal tunnel syndrome. +  


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anTkh you MEBN orf teh high luiyatq .stiucrep It emsak eeths aesxm ssrets fere adn eaelbynjo.

sympathetikey  Feels bad man. +3  
zoggybiscuits  Those Sclera sure look blue. wow. +18  
yotsubato  the same girl shows up on so many NBME exams its not even funny. Its just like that poor kidney that's cut in half that shows up in all kidney questions. +12  
aneurysmclip  I turned my brightness up and down 2 times to make sure it wasn't my brightness messing with the sclera. I'm declaring it, NBME stands for "Naturally Bad at Making Exams" . +6  
peqmd  $60 a pop and no competitors...That's what happen when there's a monopoly. +4  
peqmd  Actually they used their best software to generate images. You might have heard it before, it's called MS Paint. Quite legendary. +6  
feochromocytoma  It feels like they cranked up the contrast and saturation on a normal eye to make it look "blue"... +5  
rockodude  everyone hates on nbme, but they're showing you a picture zoomed in of her eyes and she has a history of multiple fractures/bad wound healing at the age of 4, I feel like OI should at least be a consideration based on the overall clinical picture +1  
feochromocytoma  Yeah I got it right, it's just funny that they don't use higher quality pictures for the exam +1  
djeffs1  that is clearly a malar rash... oh wait nvm just pixellation +2  


submitted by neonem(550),
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hsTi is acetu otclyhiem fnstioasnur r,aoecnit a ypet II vityiryietpenhss erhew -ereofmrpd MgI oiebaidstn inbd ot ltcaobpinmie OAB netasign no ondro s,BCR ihwhc ecsuas rraunvsialcat hs.eoiylms Rh cmiptobyitlini,a lkie oloceledrn_ d,sai ecsmo erom nito ylpa thiw mtaiRitl-hoycpib of pycnagrne and it is eud to gGI ioaedt,sibn hhiwc omre otnfe cause sratalxeuracv ymhssleio incse nelcspi egpoarasmhc avhe hsteo -ga-macmFR cporteesr to nidb rwethave gIG sha ahg.cut ravxraEtacslu 'sndeto eusca that t,nspooeyinh fevre, naklf ianp teaiosadcs whit grooheilmauinb isenc het rahagompesc dhol on to the aeddgred CRsB dna tnveocr ti to dnrieblii,v hicwh cna lasyef eb cteerdex yb hte v.reil

mousie  Could you help me with understanding why this isn't a Type I HSR? I understand that ABO incompatibility is Type II HSR but I don't know how to tell the difference between a patient who is IgA deficient and having a Type I Reaction to an infusion vs ABO incompatibility .... +8  
sympathetikey  @mousie - https://imgur.com/QH5rCEX Basically, think of Type 1 HS like a normal allergic reaction (itchy, wheezing, etc.). Whereas, with ABO incompatibility you get the question's presentation. +7  
medpsychosis  When it comes to Acute hemolytic transfusion reactions, they are Type II hypersensitivity and divided into Intravascular (ABO) and Extravascular (host Ab against foreign antigen on donor RBC). The differentiating factor between them is simple. Intravascular (ABO) will present with hemoglobinuria alongside all the other common symptoms (fever,hypotension, tachypnea etc.) Extravascular hemolysis will stand out with Jaundice as one of the presenting symptoms. Hope this helps! +5  
cassdawg  Also just to add: Rh incompatibility causes a delayed hemolytic transfusion reaction, this reaction was immediate so it is indicative more of the ABO blood group incompatibility (FA2020 p114 has all the blood transfusion reactions) +1  


submitted by ameanolacid(24),
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lCundt'o eb SLA c/b he adh rsnoeys .vmStlinnv.Ae.eoL is iytdlntics ynlo mr.oot Not meioaryilnSyg w(hhic is reupp esixietemrt nseroys neth mtoro ralet no) bc I audmsse by the ndogwri ttha lal 4 xteeisrmiet were ilvv.oden bvO ton n,oiransksP adn otn ipool bc agani, he sah troom + yren.sso

sympathetikey  Probably in part due to early age presentation, but I hear you +5  
wowo  FA2019 p518 - process of elim for other spinal cord lesions +2  
cbreland  Also syringomyelia wouldn't have a position sense issue +  


submitted by sattanki(69),
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lsMecu iapn + roraiplteib eadem si a cslsaci ropasiettnne orf chlteorlina plirsi.as etsB aiodnssgi fro ihst si a lmecus is,yobp sa the woyrm kslei to tguahno witnih het u.lsmsec

sympathetikey  That's what you get for killing polar bears. +74  
dr.xx  That's what you get for not cooking them well. +4  
charcot_bouchard  Theres nothing called "well cooked polar bear meat" +2  


submitted by lsmarshall(393),
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ACP krtoes acn uesac "gaospnipaoros" hhciw si eth litbyaiin to eionegrcz lmraiiaf afsec. seaudC by irabtalel lisosne fo svialu saioaoscnit e,asra hihcw are ttuieasd in eht inrorife cmtiloacepoiptor oertxc rmi(fsofu sy)g.ru heT atbylii to anme tasrp of het acef e.g(,. o,nse mohu)t ro ftdnyiei sdunailidiv yb orteh eucs (..eg, nlgioh,ct )ceviso si felt ctiant.

thWotui kwnongi tat,h mmnergbreei iatclicpo obel is vidovnel ni u'lasvi fu'stf r,odybla gnclndiiu geaim cseogsnrpi and tshi aitepnt si iahgnv uesssi thwi dgneursiantdn gieasm uohlsd eb uhnoeg ot get to het wranse.

gonyyong  Lol I guessed it exactly because of that +3  
sympathetikey  Never heard of that one before. Thanks! +1  
karthvee  This is not prosopagnosia, but instead a case of apperceptive agnosia. Wiki: "...patients are more effective at naming two attributes from a single object than they are able to name one attribute on each of the two superimposed objects. In addition they are still able to describe objects in detail and recognize objects by touch." Although, lesions tend to be in the occipito-parietal area so PCA again is the answer! +3  
misterdoctor69  I actually think it's both prosopagnosia AND apperceptive agnosia. She is neither able to recognize her mother's FACE nor is she able to recognize objects w/o the help of other senses (apperceptive agnosia) +  
nifty95  Yea couldn't remember the exact name but I just thought of three pathways (visual, somatosensation, and auditory) all converging somewhere/processor (probably somewhere in the temporal lobe...hippocampus?). Beyond the point, the pathways converge to an area which culminates in recognition. Cut off one of the routes (in this case visual), the other two will still work. How is visual cut off? By the PCA not supplying the area leading to neuronal death resulting in varying loss of visual function depending on the area in the occipital lobe. +1  


submitted by lsmarshall(393),
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"oomDemsse cl(aaMu ensah)erd - A -coellc-llte nonecocint that idsoevpr crutrultas prostpu htiw eenraetiditm ealifmn,st rauptialrylc in iestsus atht engruod ilnaaemhcc etrsss e(,.g. iskn, sagtcir iuss,te rb.edl)da nncsCtoe ernkstieyotac in eht asumttr opsnmusi fo the dp."eeiismr - BASMOS

sympathetikey  This is why I was looking for some answer indicating keratinocytes in the stratum spinosum...instead they just gave a bunch of bs choices. +29  
roygbiv  I'm confused because I also know that S. aureus cleaves desmoglein in the stratum granulosum, so why is it specifically this answer? +2  
duat98  desomosomes connects cells to cells. hemidesmosome connects cells to basement membrane. +2  
medguru2295  I think what this is really asking is can you tell Pemphigus Vulgaris from Bullous Pemphigoid Vulgaris (question)- Attack on DESMOSOMES- this separates some keratinocytes from others (ie some in basal layer from ones above). Pemphigoid- attack on HEMIDESMOSOMES- this means separation of the keratinocytes from the basement membrane. +2  


submitted by medstruggle(12),
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Why si it ton vroaina iocflell ?cells I ugohtth hte fmleea oaalgn fo trSleoi and edygiL si sat/rolhacagune c.lles

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +7  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +4  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +11  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +3  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +37  
mcl  But seriously though, pathology outlines says sertoli-leydig tumor "may be suspected clinically in a young patient presenting with a combination of virilization, elevated testosterone levels and ovarian / pelvic mass on imaging studies." As for follicle cell tumors, granulosa cell tumors usually occur in adults and would cause elevated levels of estrogens. Theca cell tumor would also primarily produce estrogens. Putting the links at the end since idk if they're gonna turn out right lol Link pathology outlines for sertoli leydig granulosa cell tumor theca cell tumor +12  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +5  
medpsychosis  So after doing some intense research, UPtoDate, PubMed, an intense literature review on the topic I have come to the final conclusion that...... ...... ...... ...... Wait for it.... ..... ..... Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +9  
charcot_bouchard  Hello, i just want to add that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
giggidy  Hold up, so I'm confused - I read all the posts above but I still am unsure - are sertoli-leydig cells notorious for producing androgen? +4  
subclaviansteele  Hold the phone.....Females can get sertoli leydig cell tumors which are notorious for producing androgen? TIL TL;DR - Females can get sertoli leydig cell tumors = high androgens +  
cinnapie  I just found a recent study on PubMed saying "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +2  
youssefa  Hahahahaha ya'll just bored +9  
water  Bored? you wouldn't think so if you knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
nbmehelp  I dont get it +  
redvelvet  how don't you get it that females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen? +1  
drmomo  what if this means..... females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen +  
sunshinesweetheart  hahahaha this made my day #futurephysicians #lowkeyidiots +  
sunshinesweetheart  @medstruggle look up placental aromatase deficiency (p. 625 FA 2019), it would have a different presentation +  
deathbystep1  i am sure i would ace STEP 1 if i only knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
noplanb  Wait... I might actually never forget this now lol +3  
drmohandes  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +1  
lilmonkey  Don't forget that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! You're welcome! +  
drpatinoire  Now I get it that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens. Thank you very much.. So why choose Sertoli-Leydig cell tumor again? +  
dr_ligma  The reason is because females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! This is easy to remember, as you can remember it through the simple mnemonic "FCGSLCTWANFPLOA" which stands for "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen!" +17  
minion7  after receiving a f*king score..... this post made me smile and thanks to the statement-- females can get sertoli-leydig cell tumours, which are notorious for producing lots of androgen! +1  
djtallahassee  My worthless self put adrenal zona fasciculate but now I will never forget that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
medguru2295  Wait..... so can females get Sertoli Leydig cells that produce androgens then?????? +  
peqmd  Going to snapshot this to my anki deck card: "females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of {{c1::androgens}}" +1  
paperbackwriter  Watch me f*ck up the fact that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgens on the real deal. +2  
alexxxx30  just made sure to add to my notes "Females can get sertoli leydig cell tumors, which are notorious for producing lots of androgens" +2  
peridot  I also just wanna add that if you look on in FA on p.696969, you'll see that they'll mention "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +  
mbate4  According to the literature [lol] females can get sertoli-leydig cell tumors, which are notorious for producing lots of antigens +  
drdoom  the tradition lives on +1  
jamaicabliz  Wait... so for clarification, is it that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen? Or that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen?? HELP +  
abkapoor  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen sorry for bad Englesh +  
faus305  Sertoli-leydig cells are notorious for producing lots of androgens, females can get these. +  
djeffs1  the fact that a bunch of medstudents can get so weird about how females can get sertoli-leydig cell tumors: notorious for producing lots of androgens- just made my week!! I love you guys +  


submitted by sympathetikey(1253),
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ettyrP wisdatfhr,rtgroa ubt a oodg rineedmr atht ofmlserioyisb can euasc an deenglar .lenpse

sympathetikey  Due to extramedullary hematopoesis +22  
zoggybiscuits  I thought it was spleen but the fact that hematocrit was 24% 4 HOURs later made me think otherwise. It was my understanding that the spleen would bleed you out quick! +  
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +1  
peqmd  Spleen is most commonly ruptured in blunt trauma so along with myelofibrosis and being kicked on the left side it's just asking to be ruptured +2  
limberry  @need_answers the bladder is intraperitoneal, not retro +  
limberry  bladder is sub*peritoneal, sorry +  


submitted by lsmarshall(393),
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naPteit ahs Sapni ifdiba acoctul hwhci si a nuarle ebut fdetec iafrule( of nfsuoi fo eth nr)euorosep. ecmteroolsS ear eht prta of each seitom in a teevrtbare yboemr gngiiv srie to enob or htroe ekltlsea is.estu cneiS a atrp of iths 'aienpstt ainps diabif ndliudec bcsnes"ea fo pnssoui oe"rpssc enth a mstocelore aws vvdle.nio Koniwng tath relnau beut fdceset are na essiu whti iufson hoduls be genhuo ot etg to teh thgri w.nears

fI het oohrncodt flaedi to dlpevoe tnhe eth eiernt SNC lduwo otn oplveed as het cntdorooh uscenid mfontiroa fo enarul .aelpt

If eth runael betu fdaeli to lvoedep hetn hte lwoeh SNC wdoul otn avhe edvpo.edel

okYl sac si elrvteniar ot tihs .etptina

nhWe lnuare rcset cell it sah fteefinrd moustoec ni ntreffedi .siutses iFluaer of aleunr tsrec to mietagr ni earht cna cuesa snrosoTinpati of ertga vlese,ss lraetgoyT of talF,lo ro sisePnettr sncrtuu itsroer.uas leFirua fo lenaru tscsre to eatrmgi in IG nac saceu sripcnhrgusH dessiae lngncti(eoa l)emna.ocgo chrreaTe solCnli emrSodyn can orcuc hewn nrealu srtce lcesl lifa to tegairm iont 1st elyhagarpn rcah. rlaNeu beut tcfdees hsa nhtgino ot do itwh rulfeia fo elanru etsrc tgnimaori h.thgou

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +12  
hungrybox  Fuck I picked "Formation of neural tube" but yea that makes sense... that would affect the whole CNS +3  
ruready4this  I also never heard of sclerotomes and I chose that and then switched it to formation of the neural tube because I thought that was close enough ugh close enough is not the right answer +  


submitted by sheesher(-1),
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I'm amsugnsi tath abcuees roeianabtbc si adc,eersde itsh hsa to be labitecmo scodisai dceusa by dciaazetlam?oe Mdises stih tiuqenos ceaeubs I asw nlgooik ofr bocilamet dcsoiais erdsnieac( aibobnerta)c eudsca yb a lopo .u.rcdii.te

sympathetikey  I don't think so. I know that K+ levels decrease with laxative use, due to dehydration, which activates the RAAS, which increased aldosterone, which cause Na+ re-absorption and K+ wasting. Aldosterone also causes the alpha intercalated cells to secrete more H+ into the urine, which causes a serum alkalosis. Therefore, in order to correct that, bicarb re-absorption decreases in the kidneys, which brings the pH closer to normal. As far as Chloride, I guess that must be re-absorbed with Na+ due to it being negatively charged (?). That's the one thing I'm not sure about. +5  
aknemu  I think what they are getting at is that it is Diarrhea--> Non-anion gap metabolic acidosis (HARDASS). This would mean that HCO3- would be low and chloride would be high (in non-anion gap acidosis the chloride increases and that's why you don't have a gap). +5  
2zanzibar  Normally, stool's electrolyte content primarily consists of bicarb, potassium, and sodium. Since the colon reclaims sodium in exchange for potassium, the potassium content of stool is usually double that of sodium. Most of our bicarb loss in stool actually occurs through the loss of organic acid anions, i.e. bicarb that's been titrated by the organic acids formed by bacterial fermentation in the colon (e.g. lactic acid). *Bottom line: our stool is alkaline, with mostly bicarb and potassium.* Diarrhea is a cause of *NON-anion gap metabolic acidosis* due to bicarb loss in the stool. We aren't adding any acids to the mix -- we're simply losing anions -- which is why our anion gap remains normal. Potassium goes along for the ride and we end up with *hypokalemic* metabolic acidosis. And because we're losing anions, we want to compensate by *increasing retention of Cl-*. **Anion gap = Na+ - [Cl- + HCO3-]** +3  
rainlad  another observation to support this: The patient's RR is 30/min, which demonstrates a compensatory respiratory alkalosis, in response to the non-anion gap metabolic acidosis +1  


submitted by seagull(1405),
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w"yh do'nt oyu sotp wtha uy'oer idnog asubeec tsi' .oscludu"iir -clatau- wenasr

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


submitted by mousie(210),
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pelh ihtw ihst oen e.a..lps.e si shti seacbeu he sah pyehrTG AND tllrCeehoos NAD .olcchyirn.osm ynlo LL ficdyieenc u ldponiewalx all fo ehest n?difngis I cesoh LDL R eiifcednyc uabscee I sesgu I hhgtuo ti douwl sacue lal fo mhet ot eirseacn utb is shit pety of ccifedyine yoln icdoaaesst thiw hhig LDL?

sympathetikey  First off, do yourself a favor and check this out - https://www.youtube.com/watch?v=NJYNf-Jcclo The LDL receptor is found on peripheral tissues. It recognizes B100 on LDL, IDL, and VLDL (secreted from the liver). Therefore, an issue with that would cause an increase in those, but mainly LDL. Since in this question we see that Triglycerides and Chylomicrons are elevated, that points towards a different problem. That problem is in the Lipoprotein Lipase receptor. This is the receptor that allows tissues to degrade TGs in Chylomicrons. So, if it's not working, you get increased TGs and Chylomicrons. Additionally, you get eruptive xanthomas, which are the yellow white papules the question refers to. +8  
davidw  There is much easier way go to page 94 in first aid. This kid has Type 1 Hyper-Chylomicronemia which is I) Increased Chylomicrons, Increase TG and Increased Cholesterol. It can be either Lipoprotein Lipase or Apolipoprotein CII Deficiency +12  
bulgaine  The video sympathetikey referred to only mentions pancreatitis in type IV but according to page 94 of FA 2019 it is also present in type I Hyper-chylomicronemia which is what the question stem is referring to with the abdominal pain, vomiting and increased amylase activity +  
dentist  thats not the only difference in that video.... +  
paulkarr  Pixorize has a set of videos on all the lipid disorders that made it a breeze to answer. Pixorize is basically sketchy but for biochem and other basic science subjects. +2  
futurelatinadr  Pancreatitis was a huge clue for me to think of hyperchylomicronemia +  


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antteiP si rncetru t,-edaersbf os we nca eneltaiim frsuceto ftcs(uero si fdonu ni hneyo and firtus dna soem omlfar,u but tno in rsabte mlk)i. tinaPet sah ncrdieug ubsctassen utb on slgecuo in eth nue,ir so eh mstu meso olosc-neugn u.arsg My aefdefinlrti rof iegrcdnu cnnoe-olsgu ursags ni teh eurin is idedrsros eosrtfcu iemaolmstb or gceatolsa bm.aomielts eW veha diteanmeli eofuts,cr so tath levaes su hiwt cnaetiagsokla cyieiefcdn ro scacils .iesolmataacg

sympathetikey  & Galactokinase deficiency would be much milder. +6  
smc213  Big was soybean formula not giving any issues. Soy-milk can be used as a substitute formula in patients with Classic Galactosemia since it contains sucrose (->fructose and glucose). +1  
oslerweberenu  Why can't this be glucose 6 phosphatase deficiency Confused me +  
almondbreeze  @oslerweberenu G6PD - increased RBC susceptibility to oxidant stress (eg, sulfa drugs, antimalarials, infections, fava beans) -> hemolysis; has nothing to do with presence of reducing sugar +1  
makinallkindzofgainz  @almondbreeze; Glucose-6-phosphatase deficiency is Von Gierke disease, they are not referring to G6PD deficiency (an entirely seperate disease) +6  


submitted by seagull(1405),
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im' iltsl icdoecvnn tish si laeriitrb ebowl edr.ysmon nCehga ym im.dn

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


submitted by jrod77(27),
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I hinkt yhet mgith eb edcsiibgrn oatagn..in.n urs.e T2XA is loiensresbp orf teletlpa egsaog,rngaoti ti amy be otctgiunrbin ot mosohr,isbt thus chemiisa ot teh ccdarai .eiusts

sympathetikey  Agreed. I'm pissed though because PGE2 mediates pain, which is why I picked it. +33  
he.sanchez14  If im not mistaken, the question describes unstable angina. Unstable angina is due to thrombosis with incomplete occlusion. So, yes TXA2 is responsible for the thrombus that is causing the symptoms in this patient. I'm also pissed because I also went straight for the PGE2 +5  
vik  hahah, seems like all in same boat like me +  
yb_26  thromboxane A2 is also vasoconstrictor, so my thoughts were about vasospastic angina +4  
youssefa  Went for PGE2 ... shit +  
need_answers  I went for leukotriene B4, what the hell was I doing....SHIT +12  
hopsalong  I picked Leukotrine B4 thinking that the neutrophil infiltration was the source of the pain, seems wrong lol. +  
bballhandler11  Sometimes it helps me to think of it in a general, non med school textbook kind of way. When answering, I narrowed it down to PGE2 and TXA2 as well. Then I asked myself, if someone is experiencing chest pain, would I recommend Aspirin or Advil? That's helped on a few over the counter pharm questions. +7  
ususmle  same here I M PISSED PGE2 +3  
krewfoo99  Maybe PGE2 isint the answer because it mediates pain and fever during episodes of acute inflammation? Thus making TXA2 more likely. +2  
djtallahassee  ditto on the looked at it for 2 seconds and went PGE2 +1  


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A tosobmarnl si an tuarmeim R,BC os tsi' ldtvaeee ni aestst of dsieaenrc moiaeseosthip.

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +57  
someduck3  The term "Normoblast" isn't even in first aid. +35  
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +18  
tinydoc  I wish they would stop making it so every other question I know the answer and I can't find it among the answer choices because they decided to use some medical thesaurus on us. +17  
qball  Metamyelocytes = Precursor to neutrophils Siderophages = hemosiderin-containing macrophage aka heart failure cells +8  
llamastep1  Theres a UWorld question about Parvovirus B19 that mentions "giant pronormoblasts" that helped me make the connection +5  
fexx  I got it right but would it hurt them to put RBCs? Medicine is hard as it is. No need to make the exams more complicated. I doubt my pt is ever going to as me if his/ her normoblasts are going to increase if they go hiking in the mountains +5  
mdmikek89  Even in you didn't know what Normoblast means, it cant be any of the other answers. TEST TAKIN' SKILLZ BROS +  
nerdstewiegriffin  I can guarantee you this Q was written by some sadistic PhD examiner +9  


submitted by ferrero(40),
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A yvre mrliisa etiuqnso I veah ense in saQnbk wlil ska hyw a enapitt hwit tghri rhate uirelaf oesd nto lpdeeov edeam nda teh rensaw is esceairdn ihayctplm .degniaar I got itsh snitouqe grwon liingroyla baeceus I sawedern gnalo hist eiln fo nsonarieg tbu I tkhin in htsi asec ti lal ash to od iwth EWERH hte raxet rsrsepeu is ogincm .ormf In hsit onseitqu het pt hsa itoliacds eerypnhntios os you nca nthki atoub eth eseurprs as cimogn "w"aorrdf so rsttnicncogi crpirepllaya tpnichress can tervpne an esercnai ni ursreesp ni hte alcyrapli db.e ervHowe fro trigh rahet efruila htis etarx dfliu si nmicgo romf hte TPOSOEIP irendotci kabrw(scad mofr eht ihgrt r)aeht nda tsrgicnctino rlrlcppiaaey hesinstcpr cna do tiohgnn o(n osppotie dsei fo clyarpali )edb - teh nyol yaw ot enevptr edmae si to ecsenira thyiamlcp inaeagdr.

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


submitted by seagull(1405),
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aWht a rrlibtee .ctpiure heyT eyht vceored up ratp of ti ihwt nlsie. TFW

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


submitted by seagull(1405),
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Tsih nteatip is piringtp als.bl Bteert od a grdu eerscn hwcih messe uoobs.vi

sympathetikey  When the answer is so obvious that you pick a stupid answer instead of it. DOH +37  
jooceman739  Funny thing I noticed is "he is alert and cooperative. He appears to be in pain" So he was so high that he was alert and cooperative during the basal ganglia hemorrhage +5  
yotsubato  @sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that. +1  
yogi  probably the "drug" have to be a stimulant or a hallucinogen which causes HTN & Tachycardia. +2  
charcot_bouchard  Lol. I got the right answer but took long time +  
goodkarmaonly  The patient's B.P. and pulse are raised + Bilateral dilated pupils = Most likely use of a stimulant Thats how I reasoned it anyways +  
llamastep1  Bilateraly messed up pupils = Drugs (most of the time) +  
targetmle  why is there basal ganglia hemorrhage? +  
dul071  Wait! doesn't it take like a week or two to get the results back!?!? i chose to measure catecholamine levels because that may be more timely. but clearly i'm wrong +1  
usmile1  basal ganglia hemorrhage is an intraparenchymal hemorrhage secondary to hypertension. according to FA, this occurs most commonly at the Basal Ganglia (FA19 pg 501) +1  


submitted by seagull(1405),
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ihsT is a icnpa .actakt lpHntyrvieeaitno prdso 2pCO gainled ot a torrirespay skalaos.il o2p is tvaleeryli tecfnuefad od'tn( aks em w?)oh

sympathetikey  Yeah haha I had the same conundrum. +  
sajaqua1  If she's breathing deep as she breathes fast, then oxygen is still reaching the alveoli , so arterial pO2 would not be effected. +21  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +2  
soph  Maybe Po2 is unaffected bc its perfusion (blood) limited not difusion limited (under normal circumstances). +2  
charcot_bouchard  PErioral tingling- due to transient hypocalcemia induced by resp alkalosis. +1  
rainlad  I believe CO2 diffuses ~20x faster than O2, so increases in her respiratory rate have more effect on her PCO2 than her PO2 +1  
usmile1  adding onto Charcot_bouchards comment, I found this: Respiratory alkalosis secondary to hyperventilation is probably the most common cause of acute ionised hypocalcaemia. Binding between calcium and protein is enhanced when serum pH increases, resulting in decreased ionised calcium. Respiratory alkalosis can induce secondary hypocalcaemia that may cause cardiac arrhythmias, conduction abnormalities and various somatic symptoms such as paraesthesia, PErioral numbness, hyperreflexia, convulsive disorders, muscle spasm and tetany. https://www.sciencedirect.com/science/article/pii/S1110184913000615 +3  


submitted by sympathetikey(1253),
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sh'aTt a new eo...n.

p/ec_kdipe/osktrhw/winlAog.ciasitisn/r:.yepese

sympathetikey  Makes total sense looking back. Just didn't know that was a thing :) +27  
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 +22  
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 sympathetikey(1253),
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I see htaw rheyte' sanygi hit(s asw my second ceo)hci tub at eth eams etim I elfe kile a auckbp fo blodo dulow atcvetai hte rtsrbpaeoocre dan ucsae eaecsderd htmciapetys ticyiavt to eht AS ↦ VA nd.oe

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


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Teh tntiepa sha ATN rsandecoy to erlna m.iiahsec ueD to burualt oriescns, eth ptntaie lliw vhae an elaedvte NF.ae eTh tt'anspie reniu lwli oals be l,deitu tub hsti will be rfedteecl yb teh olw irnue omol,iyltsa nto the NeaF

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? +11  
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. +37  
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! +14  
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. +2  


submitted by sympathetikey(1253),
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hotoaxeesnmeD ssreeupsps ATCH = iPartuyti eanoAsaommhoxdtn eeeD sfali ot psssepru CHTA = tcEpoci HTAC xe( - mlSal Clle Lgnu )eracCn

sympathetikey  *ACTH +  
meningitis  If im not mistaken, Dexamethosone also fails to suppress ACTH = Adrenal Gland Adenoma +1  
therealloureed  I think an adrenal gland tumor would have low/undetectable ACTH? aka no dex suppression +13  
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +12  


submitted by sympathetikey(1253),
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reP FA (.pg 66)3: gnnneCcroi bsaetr an..c.cre

"ftnicilmaoAiprir/sopeenvoexs fo entroons /sgeeropgtere psterocer or eB-cb2r R2H,E( nGF aE r)rcpeeot si mc;moon ER ,⊝ PR ⊝, 2uEdna/e RnH ⊝ mrof emro age"e.srsivg

sympathetikey  FA 2019 +4  
meningitis  Why others not it: Anticipation: Trinucleotide repeats; CAG (Huntington), CTG (Myotonic dyst), GAA (ataxia telangiectasia), CGG(Fragile X) Chromosomal rearrangement: Many but can think of Trisomy 21, BCR-Abl, etc Imprinting: Prader willi, angelman Loss of heterozygosity: loss of a single parent's contribution to part of its genome. A common occurrence in cancer, it often indicates the presence of tumor suppressor gene in the lost region. +1  
kai  trinucleotide repeats are not associated with breast cancer Neither are chromosomal rearrangements BRCA1,2 tumor supressor genes are associated with breast cancer, which is why I chose E, but I guess I should have bought the new First Aid.......... +  
charcot_bouchard  GAA is Freidrich Ataxia +4  
tulsigabbard  So is the amplification of the receptors unrelated to BRCA 1, 2? I'm still stuck on this as Sketchy states that breast cancer falls under the "two-hit" model. +  
tallerthanmymom  @tulsigabbard I think one of the keys here is the question stem; " what is the most likely cause of the OVERexpression in this pts tumor cells?" --> I think that the "2-Hit" model would lead to UNDERexpression of a tumor suppression gene rather than overexpression. Whereas amplification would cause OVERexpression of the HER2/estrogen and progesterone receptors. But, I don't think that amplification would be the answer if they were asking about a triple negative cancer. +1  
tallerthanmymom  Also this is on page 632 of FA 2018 for those using that version +  
tulsigabbard  @tallerthanmymom - thank you! +  
drzed  I can understand why @tulsigabbard dropped out of the race--she's taking step 1 soon LOL +1  


submitted by welpdedelp(216),
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I eohcs htsi cb/ sit het somt mnmcoo gotphnae orf kins fencionsti

seagull  same here +2  
sympathetikey  Some bowlsheet +11  


submitted by welpdedelp(216),
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It aws teh lony hpirleerpa gnlu can,erc sti saol emor noocmm in mn.eow tatsseMsai odluw haev sownh eumtlpil inseosl

sympathetikey  Also, lung adenocarcinoma is the most common lung cancer overall, most common in women, and most common in non-smokers. I know she smoked in the past, but that's what tipped me off to it. +5  
alexb  Yeah I literally picked SCC bc I knew she'd smoked in the past smh +  
maddy1994  20 years of non smoking history ,she wouldnt be at elevated risk for smoking related carcinoma. +2  
larryd  According to FA19 p. 693, large cell carcinoma of the lung is also peripheral. +  


submitted by sajaqua1(519),
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lCiicart onipts rof sith q:ietnsou 5 yrea old ,oby ssendppmimeusuor cuebesa of oeycr,ehtmaph 2 ady rhtoysi fo v,efer ,uhogc snshotsre of rbhate, eirfbel .1081( ,)F rpsoansertii n46,/mi hwit sinscoay nad rezineegdal escurlavi .hars nesEetivx anrodlu t.tifalrnioin

Of eht tposnio tiesld lyno ealmses dan VVZ vgei a asr.h A hsra fmro esslmae lauuyls tssrat saytlrrlo dna sdcedsne adl,aluyc and si flat nda .hutoeetmsyar By onra,ttsc VVZ pxcnhce)i(ok snpesrte ihwt eneaerglzid hars hatt cqkuiyl orsanntsiti rmfo mrulaac to lpraupa tehn ot ilracevsu.

sympathetikey  Good call. +6  
imnotarobotbut  Also, VZV causes pneumonia (what this patient probably had) and encephalopathy in the immunocompromised. +5  
nwinkelmann  What threw me off was that it didn't mention the synchronicity of the rash. I stupidly took failure to mention to mean that the rash was synchronous, which doesn't fit VZV because chickenpox rash is characterized as a dyssynchronous rash (i.e. all stages of the macule to papule to vesicle to ulceration are seen at the same time). MUST REMEMBER: don't add information not given! +5  
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +1  


submitted by mousie(210),
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Why no n?agwsiet I maen I egt stcaEys si abpybolr het gudr of oeihcc efbreo na lal tihng enadc rptay l(ol) tub on'td tdndsuenra why heret lwudo eb dlco xtieiretmes adn on nteiwsag ewhn si AF it yass aeipryhehmrt adn bd??aor??h

sympathetikey  FA says, "euphoria, disinhibition, hyperactivity, distorted sensory and time perception, bruxism. Lifethreatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome." So I think they wanted you to see Sinus Tachy and jump for MDMA. Idk why Ketamine couldn't also potentially be correct though. +11  
amorah  I picked ketamine because it said no diaphoresis. But if you need to find a reason, I guess the half life of ketamine might rule it out. Remember from sketchy, ketamine is used for anaesthesia induction, so probably won't keep the HR and BP high for 8 hrs. In fact, its action is ~10-15 mins-ish iv. +9  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +18  
fulminant_life  you wouldnt see tachycardia with ketamine. It causes cardiovascular depression but honestly i saw " all-night dance party" picked the mdma answer and moved on lol +8  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +4  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +1  
sbryant6  @fulminant_life FALSE. KETAMINE CAUSES CARDIOVASCULAR STIMULATION. +9  
dashou19  Take a look at why the patient has pale and cold extremities. "Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008716/ +3  
drzed  @sbryant6 you're both saying the same thing. Ketamine has a direct negative inotropic effect on the heart, but it is also a sympathomimetic. You are both correct. +  
paperbackwriter  @drzed Can you please site that? As far as I understand ketamine has a sympathomimetic effect on the CV system --> increased chronotropy and BP. I also don't see how they're saying the same thing. One person said "stimulation" and the other said "depression" +  
nutmeg_liver  People tend to drink a lot of water on MDMA. I just guessed the confusion was a result of hyponatremia (too much free water) but no idea if there's any data saying that people tend to become hyponatremic due to water over-consumption on MDMA lol. +1  
cassdawg  "Despite possessing a direct negative cardiac inotropic effect, ketamine causes dose dependent direct stimulation of the CNS that leads to increased sympathetic nervous system outflow. Consequently, ketamine produces cardiovascular effects that resemble sympathetic nervous system stimulation. Ketamine is associated with increases in systemic and pulmonary blood pressures, heart rate, cardiac output, cardiac work, and myocardial oxygen requirements."(https://www.openanesthesia.org/systemic_effects_of_ketamine/) +  
brise  LSD does cause HTN and tachycardia according to uworld! @d_holles +  


submitted by step420(33),
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tirniavRo bishniit 0!4YCP5 oS you cna sue it to stoob teh cnorieotnncta fo eht roeth etsoaPre intriobhsi yb tniegnvper reiht imbsamoetl by C4Y05!P

mousie  who knew +4  
sympathetikey  Right on (thanks sketchy) +6  
mguan1993  MAGIC RACKS is a good mnemonic ive heard for 450 inhibitors (macrolides, amiodarone, grapefruit, cimetidine, RITONAVIR, alcohol (chronic), cipro, ketoconazole, sulfa +3  
criovoly  "CRACK AMIGOS" Cimetidine Ritonavir Amiodarone Ciprofloxacion Ketoconazole Acute alcoholism Macrolides Isoniasid Grapefruit juice Omeprazole Sulfonamides +6  
drzed  Macrolides EXCEPT azithromycin -- they like to trick you with that one. +2  
steatorrhea  chronic alcohol induces 450, acute alcohol inhibits 450 +2  


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hyW sdeo ltehaiomnyt uasec loss of incresstae to AGCT rciinrttose e?lusnceenado oesD ihst vhae to od tihw tnmthoyilae of U to T?

methylased  GATC related to methylase --> https://en.wikipedia.org/wiki/Dam_methylase +8  
sympathetikey  Dam methylase, alright +2  


submitted by lilamk(10),
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I aedm a kyulc sgues adn osehc thsi tbu I dnt’o ithnk fro eth ihrtg .nersaso I otuhthg beaym he sha BKT nuBeif/srid’ctoncye aomAlgiiemb.nmaag B,ut nwo thta I am oingg ervo it I t’swna .ersu Wluod ttah owhs a rmalno oeutkcyle de?itfnraifel sI it ?VIDC ’Ddtni iknht CVDI oduwl ehva ebtans laerming esncetr in plymh .seond hWta slee dclou isht b?e

lispectedwumbologist  CVID presents in adulthood so it's not CVID. CVID also doesn't have absent germinal centers in lymph nodes. My dude has Bruton's agammaglobinemia +2  
sympathetikey  What @lispected said. +  


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I utthgho atth eht rpyraim hpcseatimyt onntearvini ot hte thera aws thruogh T-.T41 Wyh dolwu mloittiusna fo htsi gonailgn ont efftac kisn velesss in eht pruep ?bilm

methylased  Stellate ganglion --> sympathetics for sweat to skin in UE + head. Apparently also to increase HR (some cardiologists ablate stellate ganglion for tachy that cant be controlled by beta blockers). +  
tea-cats-biscuits  The stellate ganglion is a sympathetic ganglion, so it wouldn’t increase vasodilation in the skin of the upper extremity. Also in most people, the inferior cervical ganglion is fused with the first thoracic ganglion (T1), forming the stellate ganglion. +28  
sympathetikey  Got this wrong too. I think upper extremity skin vasodilation (which I picked) is probably more due to local metabolites. +  


submitted by aladar50(40),
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oS reh’set 001 iessdte,nr dan the veecpnalre fatre 2 sraey si =10 ta the n,nieignbg 5+ ni the sfirt aeyr, +10 ncodse ra,ye dna 3- ahtt ed,lahe ofr a oattl aenvlpeecr of 22 ntssredei or /220=2201 rncpe.et uT,sh revecnalep = vaebo hte rddaants. roF de,eiccnin sti’ 51 enw saecs uot fo 90 eseintrsd erov hte 2 sraey 001( ttola itedressn – 01 htta yladrae dah ec,lru)s ro 15 wen sluecr rep 801 ⋅etaip.nasyter isTh loduw eb 33.8 wne surlce epr 0010 aereptnaity⋅s if yuo aaprexeoldtt it otu -- ayslailcb 8000()/011 * 15 -- thsu, nedieincc = oevba hte aasdtdnr.

zelderonmorningstar  Okay I feel like an idiot cause I thought: Above the Standard = Doing a good job keeping old people from getting ulcers. Thumbs up. Below the Standard = I wouldn’t let my worst enemy into your ulcer ridden elder abuse shack. +49  
aladar50  @zelderon Ohh damn. I could totally see how one could view the answer choices that way. I think it is important to read how they are phrased - they are asking if the center is above THE standard or below THE standard. The “standard” is an arbitrary set point, and the results of the study are either above or below that cut off. Maybe if it was “above/below standards” that would work. Also, being above the standard could either be a good thing or bad thing. If say you were talking about qualifying for a competition and you have to do 50 push ups in a minute, then being above=good and below=bad. In this case, having more ulcers than the standard = bad. +4  
saynomore  @aladar Thank you!!! but how did you get the 15 new ulcers per 180 patient⋅years? I mean I understand the 15 part, but not the second part ... hence why I messed this up, lol :| +2  
aladar50  @saysomore Because the study is looking at 100 residents over a period of 2 years. Since 10 already had the disease at the start, when looking at incidence you only include the subjects that have /the potential/ of developing the disease, so 90 patients over 2 years. This would be 90 patient⋅years per year, or a total of 180 patient⋅years over the course of the study. +7  
sympathetikey  @zelderonmorningstar I thought the same exact thing. Had the right logic, but then just put the backwards answer. +3  
kai  I wonder if they chose this wording on purpose just to fuck with us or if this was accidental. My guess is there's some evil doctor twirling his thumbs somewhere thinking you guys are below the standard. +14  
symptomatology  Got it wrong!messed up in understanding options, Btw, 15/90 is somewhat 16 percent and their standerd is 50/1000 5 percent!.. this is how i knew that incidance is way up! +  
donttrustmyanswers  Patients with an ulcer are not immune to getting new ulcers --> You should include all patients at risk. But either way, the answer is the same as long as you can read NBME speak. +  
doublethinker  Damn, guess my reading comprehension is not "up to the standard" of the NBME writers. Smh. +  
prolific_pygophilic  If you forgot that its patient years (15/180) not (15/90) you still get the right answer because they are both above 5% :). +  


submitted by beeip(123),
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eTh steb I cna na,udrsetnd eheyrt' nbsicredig eorimdtlean ipahrpsaeyl, a urtsel of sexsce eongse,rt a idrsteo oemhnro ahtt tsantacerlos to teh ecusnul dna bsind sti srpitcniornat .oftrac

mousie  My exact thinking also! +7  
sympathetikey  Ditto. +  
meningitis  My thought as well but the answer says: "Binding of ligand to Nuclear transcription factor" and I thought to myself: "Estrogen Receptors aren't transcription factors.. they are receptors with Transcription Factor function that bind to the ER Element and recruit more Transcription Factors". Can anyone explain what I am missing? Am overthinking things? +  
criovoly  You are overthinking it, Steroid hormones receptor is found intracellular in the cytoplasm then they are translocated to the nucleus where they regulate gene transcription. HOPE THIS HELPS +4  
eve1000  Could this be due to the PTEN gene being linked to endometrial hyperplasia? +  
feochromocytoma  The question stem says it's glandular hyperplasia "without" atypia It's just due to increased levels of estrogen causing the hyperplasia +4  
faus305  This is a bunch of scientific mumbo jumbo +  


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eTh mtso tnmptraoi tsnhi to teh oteiqsun aer sa lwo,flso iwth #2 nbgie the mtos f:cicepsi

1) ttneiap roptser iapn wiht devherao mtoion dna perrtos cerurrtne oaverdeh omtoin irudng r.kwo dhrevaOe otmoin nac mgaaed het prnasatuisusp csmlue ued to tgpeeminnim yb eth oaiorc.nm

)2 aiPn si trows twih ietrnlna toiotran fo eht durshloe - hist si tcstesoinn iwth teh ifgdisnn of the ecaytnpm- ,etts chihw atceiinds a turspaanuspis juy.rin

mousie  I was thinking along the lines of overhead motion - damage to the subacromial bursa which is between the acromion and the supraspinatus ... also its the most commonly injured rotator cuff m. so could have guessed this one right +1  
sympathetikey  Thanks for the explanation. I was scratching my head as to why this is correct, since supraspinatus only does 15 degrees of abduction, but you make a lot of sense. +1  
charcot_bouchard  IDK WTF i picked Trapezius +34  
ls3076  why would injury to supraspinatus cause weakness with internal rotation though? +6  
targetusmle  yeah coz of that i picked subscapularis +2  
maddy1994  ya the whole question pointed to supraspinatus ...but last line internal rotation made me pick subscapularis +3  
darthskywalker306  I went for Trapezius. That shoulder flexion thing was a big distraction. Silly me. +1  
lowyield  saw someone post this on one of the other questions about shoulder... and it works pretty good for this https://www.amboss.com/us/knowledge/Soft_tissue_lesions_of_the_shoulder there's some videos in it, this specific one for the question is the neer test +  
psay1  FA2019 pg. 438 +1  


submitted by mousie(210),
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A namiagmeho si a etpy fo ngineb (coora-nncensu) rtoum in .ninatsf siTh bronamal ltrcesu fo smlla bldoo evslses raepsap on ro edunr teh ,insk lytcliyap nhtiwi eon ot rtehe eewks frate ir.thb - prd..cashigrhosnwowlwelitagmoeHmina si a rialVBpayl/c mhrbiatrk

sympathetikey  Probably a Strawberry Hemangioma since she's a baby +9  
meningitis  Can anyone explain what is option A? +1  
redvelvet  bc, it's a benign "capillary" hemangioma, we can see "thin-walled blood vessels with narrow lumens filled with blood and separated by connective tissue". It sounds similar to "arterioles in a fibrous stroma" but it's capillary. +1  
peridot  @meningitis I believe option A ("arterioles in a fibrous stroma") is describing an angiofibroma. The name angiofibroma already tells you that there is some component of fibrotic tissue involved, whereas in this case of strawberry hemangioma, the name tells you that it's more like pure blood vessels (capillaries in this case). +2  


submitted by welpdedelp(216),
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No dtei diinefcy,ec teh eapitnt ahd scseex arceotne ued ot sih ited

sympathetikey  Would never have thought of that. Thanks +8  
medschul  that's messed up dog +18  
hpkrazydesi  Excess carotene in what way? sorry if thats a stupid question +  
davidw  this is directly from Goljan "Dietary β-carotenes and retinol esters are sources of retinol. β-carotenes are converted into retinol. (a) Increased β-carotenes in the diet cause the skin to turn yellow (hypercarotenemia). Sclera remains white, whereas in jaundice the sclera is yellow, which can be used to distinguish the two conditions. (c) Vitamin toxicity does not occur with an increase in serum carotene" +7  
davidw  β-Carotenes are present in dark-green and yellow vegetables. +  
hyperfukus  ohhhh hellllll no +7  
dashou19  When I was a little kid, I like to eat oranges, like I could eat 10 oranges at once, and after a few days, I could tell that I turned yellow... +6  
cbreland  I'm okay with missing this one +4  


submitted by killme(13),
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tentoiInn ot rteTa lissanAy

usmleuser007  in a per-protocol analysis,[6] only patients who complete the entire clinical trial according to the protocol are counted towards the final results +1  
sympathetikey  "In an ITT population, none of the patients are excluded and the patients are analyzed according to the randomization scheme." +5  
smc213  This video helps https://www.youtube.com/watch?v=Kps3VzbykFQ +12  
rio19111  Thx smc213, really helped. +1  
trainingrats  Where is this in FA2019? +  
teepot123  the video explains it well, no need for fa +  


submitted by sympathetikey(1253),
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aseC eeSirs

A uogpr ro eisrse fo seca errtsop vivignoln saptteni who ewer egnvi ialrsim ra.etmtent tRsrpeo of aces sisree aslulyu tnancoi didtelea rnoontifima atuob eth idnliiuavd t.eansitp hTsi lesndiuc omgephiadrc troofianinm rfo( emaxe,lp g,ae rndg,ee ctnhie no)irgi nda iofaiormntn no igo,sdnsia aeretm,ttn peeronss ot ,tnearmtte nda lopwu-flo eratf ttarmeen.t

In isth nitequos, it ksloo leki ehyt n'tddi lerlya fsocu on eht atmertetn aptr fo ti tbu siwoerhe,t eksam neses

sympathetikey  Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/case-series +2  
ngman  I think another factor is that in case series studies there is no control group vs case-control, cohort...ect +18  
leaf_house  "There is often confusion in designating studies as 'cohort studies' when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998589/ +  
fataldose  explanation of one of the wrong options - correlational study A correlational study is a type of research design where a researcher seeks to understand what kind of relationships naturally occurring variables have with one another. In simple terms, correlational research seeks to figure out if two or more variables are related and, if so, in what way. (source - https://study.com/academy/lesson/what-is-a-correlational-study-definition-examples.html ) +  
j44n  you dont need a control group in a cross sectional one so how do you differentiate that +  


submitted by hayayah(1056),
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rnIo soedorev si a uacse of a ihhg innoa apg liamoctbe .dsiioacs

meningitis  I found this to add a little bit more explanation as to how it causes the acidosis if anyone needs it. 1. Mitochondrial toxicity - decreases aerobic respiration and shunts to lactic acid production 2. Cardio toxicity (Secondary to Mitochondrial toxicity) leads to cardiogenic shock (hypoperfusion), which causes lactic acidosis 3. Hepatotoxicity - Decreases lactate metabolism, causing lactic acidosis 4. When in trivalent form (Fe+3), it can react with 3 molecules of H2O --> FeOH3 + 3H+ This will then deplete Bicarb buffering system resulting in non-gap acidosis. Source: https://forums.studentdoctor.net/threads/iron-poisoning-anion-gap-or-non-anion-gap-acidosis.958285/ +17  
sympathetikey  None of the other choices were even metabolic acidosis. They threw us a bone with this one. +21  
imnotarobotbut  Don't changes in bicarb take a few days? How did his bicarb drop down to 8 in 12 hours? +2  
charcot_bouchard  its met acidsis. not compensation +7  
j44n  they did throw us a bone however I didnt catch it +1  


submitted by louisville(12),
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u-tbllehyeeMne sieatnd acelf rsema redevel omrusnue hrtuliopnes (tbu tno yan arni).mgsos llgSihae si rolslsceo ehnw nsideat ihtw mleyhente eubl; E clio nstais ebul ihwt yneethlme lube ceauebs it tmeesfrn ta.olsec

sympathetikey  E. coli stains green (just fyi) otherwise, perfect. +13  
chandlerbas  only E coli stains green, all other lactose fermenters stain purple/black (just fyi) otherwise, perfect. ;) FA144 bottom +4  
dmotav  I think this is actually a separate concept – E. coli stains "metallic green" on eosin methylene blue agar, which is in the E. coli sketchy and first aid. However this question is referring to the methylene blue test on a fecal smear. From what I can gather, this test will be positive (indicated by presence of neutrophils) in cases of invasive diarrhea (i.e. shigella, salmonella, enterohemorrhagic E. coli). The test will be negative (no neutrophils) in cases of diarrhea caused by toxins (cholera, enterotoxigenic E. coli, giardia, viral diarrhea). So even though E. coli can present with fecal PMNs (if it's the enterohemorrhagic type), I guess that's less likely than shigella? source: https://www.ncbi.nlm.nih.gov/pubmed/4554412 +3  


submitted by hayayah(1056),
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nPtteai hsa umardlely ocam.cirna ignlantMa orpeiinrltoaf of aciraporfaulll "C" lcles hatt ucoeprd nioactcinl dan avhe esshte fo lcsle ni an oliaydm rta.mos

xxabi  Just to add - patient likely has MEN 2A or 2B with the presence of medullary thyroid cancer and pheochromocytoma +13  
sympathetikey  @xxabi Was going to say the same thing. +  
dermgirl  The patient have MEN 2B (Medullary thyroid carcinoma + Pheochromocytoma) Page 351 FA. +  


submitted by hayayah(1056),
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limaFila dsanamteuoo lpsyopsio si na solauamto toaimndn nmo.tiatu Tdohausns fo olpyps sriea tatrisgn refat uby;etrp cno;olipanc laaswy lnsiveov tcuerm. clocthrpaPyi cetymcolo or slee 0%10 rsopsger ot C.RC

soAoltmua nniomtad essidaes hav,e no vaar,ege %05 acehcn fo bngie spdsea dwon ot npig.ffosr

sympathetikey  I would say this is Lynch Syndrome (APC is usually thousands of polyps) but lynch syndrome would generally have a family history of other cancers as well, so you might be right. Either way, both autosomal dominant so win win. +2  
smc213  uptodate states: Classic FAP is characterized by the presence of 100 or more adenomatous colorectal polyps +  
dickass  @sympathetikey Lynch Syndrome is literally called "Hereditary NON-POLYPOSIS colorectal cancer" +9  
fatboyslim  I think this actually is Lynch syndrome. Lynch syndrome can also develop colonic polyps but not nearly as bad as FAP. FAP has so many polyps you can't even see the normal mucosa. If you Google Lynch colonoscopy you can see that they develop a few polyps. +  
rockodude  I forgot it was AD inheritance but regardless at the time I was confused because APC is a tumor suppressor so it needs two hits. I guess AD inheritance and then you need another hit to develop CRC kind of like familial retinoblastoma or li fraumeni syndrome +  


submitted by hayayah(1056),
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Stivyensiit tesst are dsue rof irngen.ecs fScyiiticpe tetss ear edsu fro ainoontmicfr eraft psieoivt crn.igseesn

invtSstyeii tetss aer edsu fro esigne hwo nyma eppelo tyulr evha the eedis.sa etcyifciSip sestt ear rfo etsoh ohw do ont hvae the as.eised

A ighyhl nstsiieve ets,t ehwn nievaeg,t elurs UOT ie.sdase A ghilyh ficsiepc ,estt hnwe eispovti, lruse NI ds.asiee ,So a stet tiwh twhi wol isvnitestiy tncoan luer otu a sedaie.s A stte twih low yiiifesctcp n'cat eurl in sasdee.i

The orctdo nad napetit wtan to sencre orf cnolo nrceac and erlu it o.tu The cootdr olduw atwn a sett iwth gihh yvisinsttei to be bale to od ttha. He okswn ttah ttneisg her otols fro lbood will tno luer uot hte oiiyptbliss of nocol .CA

sympathetikey  SeN Out (Snout) --> sensitive test; - test rules out SPec In (Specin) --> specific test; + test rules in +21  
usmlecrasher  can anyone pls explain why it is not << potential false- positive results >> ??? +  
almondbreeze  correct me if I'm wrong, but 'high FP (choice C)=low specificity (choice B)'. Whereas high specificity is required to rule in dz +2  
almondbreeze  picked positive predictive value myself. can anyone explain why not PPV? +  
williamfreakingosler  The principle @hayayah is talking about (a negative test being relied upon to reliably rule out) is negative predictive value ("NPV"). I don't see why "uncertain NPV" isn't the correct answer, particularly because NPV is predicated on the disease having the same base rate in the person(s) being tested as in the population that was characterized for the test statistic. Given that the patient has a strong family history of colon cancer, the NPV of FOBT is uncertain. Said another way, the sensitivity of a test does not change with the population, but the NPV does. The whole reason the doctor is denying FOBT is because of bayesian thinking (a priori information related to family history), and from my point of view bayesian logic is more relevant to PPV/NPV than to sensitivity, hence my confusion over why NPV isn't the right answer. +2  
ibestalkinyo  I thought negative predictive value for the same reasoning +  
raga7  AFTER THE RESULT OF TEST WE CAN USED PPV OR PPN, BUT FOR TEH FIRST TIME LOOKING ANY DESEASE USE SENSITIVITY OR SPECIFICITY. +  


submitted by step420(33),
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htrOe ydnike shtryepeprHoi eud to edincaesr rsesst -;t-&g nto rayshpilepa cb ton neaocscur

masonkingcobra  Above answer is incorrect because hyperplasia can be either physiological or pathological. Prolonged hyperplasia can set the seed for cancerous growth however. Robbins: Stated another way, in pure hypertrophy there are no new cells, just bigger cells containing increased amounts of structural proteins and organelles. Hyperplasia is an adaptive response in cells capable of replication, whereas hypertrophy occurs when cells have a limited capacity to divide. Hypertrophy and hyperplasia also can occur together, and obviously both result in an enlarged (hypertrophic) organ. +37  
johnthurtjr  FTR Pathoma Ch 1 Dr. Sattar mentions hyperplasia is generally the pathway to cancer, with some exceptions like the prostate and BPH. +4  
sympathetikey  Tubular hypertrophy is the natural compensation post renal transplant. Just one of those things you have to know, unfortunately. +2  
charcot_bouchard  Isnt Kidney a labile a tissue & thus should undergo both. This ques is dipshit +  
brbwhat  Dr Sattar says, kidney is a stable tissue, at least pct is as seen in ATN. But I read, basically kidneys are mostly formed whatever number of nephrons have to be formed by birth, after that they can only undergo hyperplasia aka increase in size/or regenerate if need be in case of atn. We cant have more number of nephrons. +1  
mambaforstep  @brbwhat , do you mean kidneys can only undergo hyperTROPHY? +2  
j44n  .... you're not making more cells..... so it cant be hyperplasia +  


submitted by ark110(1),
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utB awht si het crieednffe etbeenw toionp A dan tnopio C 3(21; 4;.9 09; 5)3

sympathetikey  K+ shouldn't increase. It's moving into cells due to metabolic alkalosis. +  
home_run_ball  In the parietal cell of the stomach Hydrogen ions are formed from the dissociation of carbonic acid. Water is a very minor source of hydrogen ions in comparison to carbonic acid. Carbonic acid is formed from carbon dioxide and water by carbonic anhydrase. The bicarbonate ion (HCO3−) is exchanged for a chloride ion (Cl−) on the basal side of the cell and the bicarbonate diffuses into the venous blood, leading to an alkaline tide phenomenon. +1  
ergogenic22  RAAS increases from volume loss, and thus more aldosterone leads to low K+ +1  
sinforslide  Three reasons for hypokalemia. First, some K+ is lost in gastric fluids. Second, H+ shifts out of cells and K+ shifts into cells in metabolic alkalosis. Third, ECF volume contraction has caused increased secretion of aldosterone. +3  


submitted by hayayah(1056),
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coNit,e eht tsme says reropss"rco ni het iskn"

D3 ce)ellfachro(ocil mfro epsrouxe of knis ts(uamrt abeas)l to nus, inneositg fo is,fh k,mli lnatsp.

D2 )icarle(feoglorc rmfo iogtisnne fo at,nspl f,ngui .asetsy

Bhot venotderc ot HO25- D3 gaters(o from) ni eivrl nad to teh eviact rofm 1O,)H252(- 3D ilcl(itroa)c ni dknyei.

sympathetikey  C is the 3rd letter in the alphabet. Hence, D3 = Cholecalciferol +4  
karljeon  Thanks for the explanation. The question stem made it sound like "what future step will be decreased?" Actual question: "Decreased production of which... is most LIKELY TO OCCUR in this patient?" Maybe NBME needs a grammar Nazi working for them. +8  
bharatpillai  question says "decreased production of which of the following precursors in skin is most likely to occur in this patient? the answer has to be 7-dehydrocholecalciferol! +4  
bharatpillai  7 dehydrocholesterol +2  
brbwhat  Yeah i did the same, but then realised acc to uw flowchart 7dehydrochole.. is converted to cholecalciferol in presence of uv rays. So the decreased precursor would be cholecalciferol since we already have 7 dehydrocholecalciferol not being converted by uvrays Tho the uw chart sites both ergo and chole as dietary sources. +2  
drzed  Wouldn't 7-dehydrocholesterol build up in the skin? Since UV rays convert 7-dehydrocholesterol into cholecalciferol, if you are lacking the conversion, the reactant (7-dehydrocholesterol) should accumulate. +  
brbwhat  They’re asking decreased production of which of the following precursor would occur? 7 dehydrocholestrol builds up, but decreased production of cholecalciferol takes place, which is a precursor in the pathway for vitamin d formation +1  


submitted by strugglebus(163),
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sA na d:1 e81it00,0 ppeloe peeorrtd ot ehav dsei tfefesc henw tgknia idniAgydtrocm.hoo holrHeza m,het 52 poelep %)(20.0 hvae Bestra rgsdaihec

neonem  I think the best way to answer this question was by process of elimination. +1  
sympathetikey  That's some bullshit lol +8  
karljeon  Haha I eliminated the answer by process of elimination. +19  
medschul  I eliminated thiazides by process of elimination :( +1  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +2  


submitted by strugglebus(163),
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So yuo wnko atth %65 fo the atda lliw flal nhwtii D1S of het maen. oS if oyu cstbuatr 1-5600 oyu ilwl teg 53. cWhhi easnm tath abtou 1%6 lilw fall bveoa nda 1%6 wlli afll bowle 1 S.D yThe ear nskgia ofr who aymn wlli allf aevbo 1 .SD 'Im user erhte is a eerbtt ayw fo oindg ths,i ubt tasth hwo I gto ti ll.o

sympathetikey  Same! +6  
sympathetikey  Except according to FA, it's 68% within 1 SD, so 34%, which split in half is 17%. +2  
amirmullick3  Sympathetikey check your math :D 100-68 is 32 not 34, and half of 32 is 16 :) +8  
lilyo  Can anyone explain why we subtract 68 from 100? This makes me think that we are saying its 35% of the data that falls within 1SD as opposed to 65. HELLLLLLP +  
sallz  @Lilyo If you consider 1 SD, that includes 68% of the population (in this case, you're saying that 68% of the people are between 296 and 196 (1SD above and 1 below). This leaves how many people? 32% outside of that range (100-68=32); half of those would be above 296 and the other half below 296, so 16% +5  


submitted by strugglebus(163),
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oS yuo ownk tath %65 fo eth data wlli alfl hiwitn DS1 of eht .maen So if uyo bcsttura 005-16 oyu will tge 35. hWich nemas atht auotb 1%6 ilwl allf vboea dan 6%1 iwll lfal oelwb 1 D.S yeTh ear asingk ofr who anym llwi lafl evboa 1 S.D I'm ures reteh si a rteetb ayw of diogn ,hsti utb taths woh I tog it llo.

sympathetikey  Same! +6  
sympathetikey  Except according to FA, it's 68% within 1 SD, so 34%, which split in half is 17%. +2  
amirmullick3  Sympathetikey check your math :D 100-68 is 32 not 34, and half of 32 is 16 :) +8  
lilyo  Can anyone explain why we subtract 68 from 100? This makes me think that we are saying its 35% of the data that falls within 1SD as opposed to 65. HELLLLLLP +  
sallz  @Lilyo If you consider 1 SD, that includes 68% of the population (in this case, you're saying that 68% of the people are between 296 and 196 (1SD above and 1 below). This leaves how many people? 32% outside of that range (100-68=32); half of those would be above 296 and the other half below 296, so 16% +5  


submitted by sympathetikey(1253),
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As teadst ow,ebl teh etLf crus ercerib saw daamedg (ees wath ti ushold ynrlaolm oolk ekli b)low.e Tihs nniotasc het caionprtscoil tatrc. enSic eth nloaiccrsiotp tatrc ueaecdsst ta the ,mlladue eolwb het rniadibm noicest 'were iogkoln ,ta uyo lwuod ees llaorraCttnea )h(gtRi aStcpsi eirpHsmisae

hello  What identifies that a cross-section is medulla vs midbrain vs pons? +4  
kernicterusthefrog  @hello I like to pay attention to the Cerebral Aqueduct (diamond/spade shape seen mostly in Midbrain, and transitioning to 4th ventricle in rostral Pons), and then the shape and size of the 4th ventricle as you move down Pons to rostral&middle Medulla, and eventual closing and absence of fluid space at caudal Medulla. +11  
hello  @kernicterusthefrog Thank you. +  
mbourne  NGL, I thought the right side had the pathology lmao ty +20  


submitted by hayayah(1056),
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TIRN's era setadaicos whti lpeisobs edsi tfsfeec of ,aaenmi y,cagnourinlaetpo adn perssusp.ynolmeoi

sympathetikey  Especially zidovudine. +17  
fmub  Nucleoside reverse transcriptase inhibitors (NRTIs) block reverse transcriptase (an HIV enzyme). HIV uses reverse transcriptase to convert its RNA into DNA (reverse transcription). Blocking reverse transcriptase and reverse transcription prevents HIV from replicating. +1  


submitted by strugglebus(163),
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Teh CI euavl identanoc 1, hiwhc manse htta tis iitgifsninnca

sympathetikey  Correct. Per first aid: "If the 95% CI for odds ratio or relative risk includes 1, H0 is not rejected." +1  
xxabi  Ah that makes more sense, thanks! +  
drdanielr  Since the OR or RR is a ratio, if the two interventions are equal the ratio would be 1. So, if the CI includes 1, they are "the same" or not stat sig diff +  


submitted by monoloco(132),
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rAnunal rcpasnae si teh nlyo nesawr htta onsacutc ofr eht beli in the imov;t of het hse,iocc it is teh ynol onortsuictb sldiat to wrhee ebli eensrt teh GI cratt.

ergogenic22  Meckel diverticulum also occurs distal to the CBD but less likely to be associated with bilious vomiting +  
sympathetikey  Correct. Might cause pain due to ectopic gastic tissue. +3  


submitted by strugglebus(163),
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I cshoe tsih llesoy eabusce ti saw so nadm pfcseici

sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +4  
karljeon  I didn't choose it because it was so damn specific. :( +40  
lovebug  Could anyone explain for B) for me? because I choose B).:( +2  
j44n  B.) is wrong because its never been shown to show adverse effects "any offcial data linking the drug" and the fact that it's "newly marketed" +  
j44n  and because its in 5/45 patients roughly 10% of the population, that might not seem like much but most of the diseases we freak out over are in 1-2% of the population, to put that into perspective if we gave this drug to every person in the US (every big pharma wet dream) with a population of 300 million... 30 million people would have this adverse event... hope that helps +  


submitted by ergogenic22(301),
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A tsecrth nrujyi iugdrn ribdhctilh ilwl retusl in aamged ot eth atnrexle earulreht adn alna spcihtensr dan edgama to eht luapndde enerv -S.(42)S Tihs cna dlae ot eecardsed noaetinss in eht erpialne nad gtiaeln reaa dan aelcf ro auyrinr eincetninnco

thepacksurvives  I think that there can also be a direct tear to the anal sphincter muscles +5  
sympathetikey  A better answer choice would have been "damage to the nerves innervating the anal sphincter" but eh, ok. +20  
nerdstewiegriffin  I it is due to actual tear of external and or internal anal sphincter Source uptodate +2  


submitted by monoloco(132),
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This is irielcdynt sgknia oabtu pake beon snytid.e haTt wolhe gtihn aoutb gahiirtgnbw-ee erescxesi, igntea trigh, aday daya, before nad guridn thta w-opondsle aphes of fiel ofr nboe sndt.yei llA botau ncriegdu ttah 1% pre ryea lr-aedeteag eonb yndtsie ossl sa tseb sa we .cna vleeL of vitiacyt is syieplrec ielk bain-wtrigegeh ecreexs.i oeidsnr(:C on vyct,aiti d-reddnbie -- sya dogobey to yrou bo;nse ighlyh ,teaicv rsun ereyv rohet day -- odgo onumat of -htingigewebar / sesstr ot dcenui geidemolrn adn tiiannma erigttnyi of the ).osneb

sympathetikey  Yeah, I was thinking about that while taking the exam. Just got thrown off because I don't see how that matters, now that they've fractured the femur. How do prior increases in bone density allow for better chances of bone healing? +12  
rsp  I think that bone density is important here, but think about all of the other things that go in to recovering from a fracture at that age too. How strong are the muscle that will stabilize you while going through the motions of physical therapy? How conditioned are you? +2  


submitted by meningitis(502),
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enhW tnigadsn up, eht boyd ymrllnoa etvcitasa ahysemptcti tssemy to aoivd cstootitahr enosnpyt.hio

uBt scnei teher si now an tddeiaiv tefcef fo het toreychpamchoomo cgd,iernsrea it ilwl leda ot a ertespynnhoi

e:(.i loebDu sctnoitoiasorcnv = Peho rdcgraeseni + taptehymicS stes)my

sympathetikey  Brilliant. +5  
medschul  Would pheo have a normal resting BP though? +10  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +7  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by mrmassador(10),
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I tkihn eht point of teh isoentqu is to zoreneigc that itsh si a lirointhdcmao eesiasd emr(hto and anlatemr gnratmeohdr wree .tfd)eeafc dsuoecPr idwe ngare of ,tfefsec btu ucseml waeksesn adn smoe gonceoulir fitsecid tosdo uot ot em. oAls hits: hTsinTn//ohsn#etMgl/mg:oi.gLdicrn/htp-.ent1vo.

sympathetikey  Yes, but doesn't that mean maternal transmission? Men can have these diseases too, they just won't pass them on. +28  


submitted by hayayah(1056),
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A ibg ihntg ereh oot is ntgoicin ahtt eth ALP si ee.sdacred asOlsoetbt iiyctatv si sedreaum yb beon .APL I tkinh ttah was teh inma fucso hree nda nto taht oyu iearncssley need ot nkwo eth 1CABF eeng tianmtuo.

sympathetikey  Exactly. That's the only way I got to the answer. +3  
pakimd  isnt increased alk phos consistent with increased osteoblastic activity? +  
champagnesupernova3  A defect with chondrocytes would cause an short limbs like in achondroplasia so those are ruled out +  
pg32  Exactly. Can also be helpful if you remember that the clavicles are formed by intramembranous ossification rather than endochondral; that allows you to rule out the chondroblast/cyte answer choices. +4  


submitted by monoloco(132),
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nspuealtdEca moiarssgn rnu pantmar ni pnatiets who vaeh on nle,pes hrthewe hpsyallyic ro nfanul.tcyloi (clealR eth wa-ryiedar of eauesalq eskcli lcel attinpse nereixpcee haknts to htier lnucfoiatn oucne.a)toympstel

sympathetikey  Agreed -- went with E. Coli like a dingus, just because I didn't associate DIC with S. Pneumo. Thought it was too easy. +  
chillqd  Isn't E. Coli also an encapsulated organism? What makes Strep pneumo more likely in this question just because its the more common cause? +23  
studentdo  Pseudomonas aeruginosa is encapsulated as well. I think the right answer has to do with DIC but why? +1  
mgoyo89  The only reason i found was S. pneumo is more common, I went with Pseudomonas because of the "overwhelming sepsis" :( +1  
kard  Everyone is correct about the Encapsulated microbes, but this is one of those of "MOST LIKELY", and by far the most likely is S.Pneumo>>H.infl>N.Mening. (omitting that patients with history of splenectomy must be vaccinated. +1  
djinn  Gram negative are more common in DIC my friends +2  
drzed  Correct me if I am wrong, but I am pretty sure that E. coli is NOT a common cause of pneumonia because it must be aspirated to enter the lung. Thus, only patients with aspiration risk (e.g. stroke, neurogenic conditions) would be at a chance of getting E. coli pneumonia. +1