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Contributor score: 1600


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 +8  visit this page (nbme21#26)
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The whole "picks at the lesion...causes some bleeding", made me think Psoriasis. Should have gone with Actinic Keratosis based on the patient history (lots of sun exposure).

Actinic Keratosis

Premalignant lesions caused by sun exposure. Small, rough, erythematous or brownish papules or plaques. Risk of squamous cell carcinoma is proportional to degree of epithelial dysplasia.

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thisisfine   Same - the bleeding thing pushed me over to psoriasis as well. Oops. +6
temmy  the distribution of the other lesions, forearm, face, ear, scalp..is not characteristic for psoriasis. +8
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 +7
hyperfukus  oh last thing psoriasis itches! they said no itching +7
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. +3
amy  Why not squamous cell carcinoma itself? +
amy  nevermind, I think the 8 year history explained it +

 +8  visit this page (nbme21#40)
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Good picture: https://teachmeanatomy.info/wp-content/uploads/Contents-of-the-Cavernous-Sinus.jpg

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 +2  visit this page (nbme21#34)
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Inferior oblique = helps you look up & in.

Also, they said floor of the orbit, so it makes sense that the inferior muscles would damaged.

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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 +7
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. +16
chandlerbas  bam! dr_jan_itor just cleaned up that confusion +2
weirdmed51  Why inferior oblique then? Doesn’t IO helps to look up ? +1
freemanpeng  May be IR is stronger than IO in downward gaze? +

 +3  visit this page (nbme18#32)
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Person probably has Irritable Bowel Syndrome. Regardless, it seems like they're trying to treat symptoms with an oipoid anti-diarrheal like loperamide.

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cbreland  "intermittent" made me think IBS as well +
heenaasnani  Was i the only one to think that it could be carcinoid syndrome as it is episodic? +
heenaasnani  tumor* +
heenaasnani  I thought it is a carcinoid tumor and not a syndrome yet, as the patient has only GI manifestations. Can someone explain why can't it be that? +
fatboyslim  @heenaasnani even if it was, there is no answer choice targeting treatment of carcinoid, which would be octreotide (somatostatin analog). I agree with you though, carcinoid was on my differential while reading the question. +

 +5  visit this page (nbme18#22)
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A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Other may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention.

https://en.wikipedia.org/wiki/Cystocele

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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 +5
mkayman  and just for completeness, rectocele would have a posterior vaginal wall bulge +2
mkayman  and just for completeness, rectocele would have a posterior vaginal wall bulge +

 +5  visit this page (nbme18#5)
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Appears to be fibrin deposition secondary to bacterial peritonitis.

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 +3  visit this page (nbme18#42)
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• Pompe Disease (Type 2)
    ○ Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase)
    ○ Buildup of 1,6 linkages
    ○ Presentation:
        § 1. Cardiomegaly
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sympathetikey  *1,4 glucosidase +4
handsome  what is the meaning/significance of 16.8difficult score? +

 +6  visit this page (nbme24#23)
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Better picture - https://www.earthslab.com/wp-content/uploads/2018/01/Buccal-Nerve.jpg

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yb_26  @at0xibolic, I think you won this competition on finding better picture lol thanks +6
drschmoctor  Those may be better, but this is the BEST. http://bitly.com/98K8eH +21
brotherimodu  god damnit +2
jesusisking  Not again (´∀`) +2

 +12  visit this page (nbme24#37)
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As per Pathoma,

"Vascular permeability occurs at the post-capillary venule"

This is why, when you have edema, you would have gaps in the venules.

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j44n  that was my exact reasoning +3

 +4  visit this page (nbme24#23)
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I just tried to think of what's released by the Adrenal Medulla (Epinephrine). PNMT is the only choice that made sense.

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 +46  visit this page (nbme24#33)
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Everyone who got this question right is a cop. ༼⌐■ل͟■༽

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dr_ligma  Fkn narcs +2
j44n  whippet_gang +

 +7  visit this page (nbme24#49)
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Pretty straightforward, but a good reminder that myelofibrosis can cause an enlarged spleen.

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sympathetikey  Due to extramedullary hematopoesis +31
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! +1
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +4
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 +3
limberry  @need_answers the bladder is intraperitoneal, not retro +
limberry  bladder is sub*peritoneal, sorry +

 +6  visit this page (nbme24#19)
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Buzzword: excessive tearing

Cluster headaches, in questions, always come with autonomic symptoms.

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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 +

 +10  visit this page (nbme24#24)
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Pediculus Humanus

Blood-sucking lice that cause intense pruritus with associated excoriations, commonly on scalp and neck (head lice), waistband and axilla (body lice), or pubic and perianal regions (pubic lice).

Best give away in this question, for me, is the "white, globular protuberances". Looks just like the pic in First Aid 2019 (see below).

https://i.imgur.com/mh5JA2D.png

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aaftabsethi1  How the hell did pediculus spread in the class . Who is having head to head contact there ? +
impostersyndromel1000  they probably were assigned group projects where the teacher asked them to put their heads together ;-) +1

 +5  visit this page (nbme23#28)
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Keys were the:

-Glucosuria

-Phosphaturia

-Amino aciduria

Those should be re-absorbed by the PCT, so if they're not, Type 2 RTA.

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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. +

 +14  visit this page (nbme23#42)
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Classic homocystinuria.

See this pic of the section for it in FA 2019 - https://serving.photos.photobox.com/78796525c8643c0eceea53592c7d63f81a0642564e58c186ae2b83438c7bf2bf16672796.jpg

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 +4  visit this page (nbme23#50)
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I see what they're saying (this was my second choice) but at the same time I feel like a backup of blood would activate the baroreceptors and cause decreased sympathetic activity to the SA & AV node.

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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). +10
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +

 +8  visit this page (nbme23#6)
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Seminoma is the most common testicular tumor. It's a germ cell tumor. Commonly see "fried egg cells".

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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. +15
an1  @drschmoctor we're really heavily targeting the wrong gender for birth control then... +3

 +16  visit this page (nbme23#27)
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Any time you see fixed wide splitting of S2, smash ASD.

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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... +
an1  I was stuck between Aortic insufficiency or ASD. I opted for ASD because Aortic insufficiency is usually referred to when there's aneurysm or something, leading to the valve being insufficient to close and causing regurgitation (which is a diastolic murmur). I've seen this word used mostly with regurgitation, just a thought +

 +5  visit this page (nbme23#49)
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Acute gout treatment:

  1. NSAIDs
  2. Steroids
  3. Colchicine

I, like a dumby, misread -zone for -sone, thinking it was steroid picked that. For anyone who cares, Sulfinpyrazone competitively inhibiting uric acid reabsorption in the proximal tubule of the kidney.

Source: https://en.wikipedia.org/wiki/Sulfinpyrazone

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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 +6
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

 +4  visit this page (nbme23#16)
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Source: https://en.wikipedia.org/wiki/Myelin

"myelin speeds the transmission of electrical impulses called action potentials along myelinated axons by insulating the axon and reducing axonal membrane capacitance"

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littletreetrunk  I think this makes total sense, but how does it not ALSO stop fast axonal transport? +5
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." +5
yotsubato  axonal transport is mediated by kinesin and dynein. Microtubule toxins like vincristine block these +4
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  visit this page (nbme23#25)
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Pain & temperature fibers for the right side come in on the dorsal right side, cross at the anterior white commisure, and travel up in the Spinothalamic tract.

https://lh3.googleusercontent.com/-B4YXuXT68ts/V2Wu-kGlZyI/AAAAAAAAljk/3j2iHrI9hQ4/s640/blogger-image--1680479964.jpg

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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/ +

 +19  visit this page (nbme23#32)
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Tough question.

Recall that Memantine (alzheimer's drug) is a NMDA Receptor Antagonist that helps prevent excitotoxcity by Blocking Ca2+ entry. That's how I remember this.

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veryhungrycaterpillar  https://www.jneurosci.org/content/10/3/909.short Great little read, and this is the paper they pretty much based this question on. +
veryhungrycaterpillar  Linked the wrong paper. Meant to link this one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2867560/ +

 +6  visit this page (nbme23#22)
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Believe this question is referring to Visceral Leishmaniasis.

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gabeb71  The give away is the Fever, Pancytopenia, and Hepatosplenomegaly after being bitten by an insect and developing the sore. +16
tallerthanmymom  I got this question directly after the other visceral leishmania question and it made me second guess everything I thought I knew. +11
qball  Don't forget they like to infect macrophages. +1

 +6  visit this page (nbme23#6)
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Lucky deduction, but looking back, I believe what they were going for is what she should have been vaccinated for at 6 months of age (since there are no apparent symptoms).

Hep B vaccine is usually given at birth, 1 month, and 6 months of age, so it's pretty important that she be vaccinated against it, unless she already has it, in which case she should be treated to avoid cirrhosis.

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ls3076  how can we actually be expected to know vaccination schedules... there must be some other reason the answer is correct +5
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) +1
koko  Why does it have to be something with a vaccine? RSV Is extremely common in babies,shouldn’t screen for that? +1
makingstrides  I didn't get my hep B vaccine until I was a teen +2
srmtn  it is related to the screening during pregnancy, nothing to do with vaccines. +2

 +2  visit this page (nbme20#49)
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Direct Antiglobulin = Direct Coombs Test

Detects antibodies bound directly to RBCs. Hemolysis most likely due to something in the transfused blood (not sure why it took 4 weeks when Type 2 HS is supposed to be quicker but w/e).

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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/ +7
hungrybox  such a dumb question wtf +31
sonichedgehog  takess longer due to slow destruction by RES +1
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. +3
tomatoesandmoraxella  The Uworld table is in question 17780 +3
lukin4answer  Delayed Hemolytic transfusion reaction is Host IgG against donor's RBC Rh or minor blood group Ag.(details on UW 17780), we do direct COOMB test where we add "ANTI-immunoGLOBULIN Ab" to patient's blood, if RBC is coated with IgG, then they agglutinates. As we add "ANTI-immunoGLOBULIN", hence this direct coomb test is called = DIRECT ANTIGLOBULIN test (DAT). I got it wrong too, then dug through. UW Q 317, 891, 1851 mentions COOMB TEST= Direct ANTIGLOBULIN TEST :/ :/ :/ & it's usually the INDIRECT BILLIRUBIN that rises with hemolysis, not direct (option C) +2

 +14  visit this page (nbme20#26)
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Good picture showing the anatomy of the thigh from a T2 MRI perspective.

https://radiologykey.com/wp-content/uploads/2016/01/B9781437707595000073_u007-009-9781437707595.jpg

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jcmed  Was so close to picking vastus intermedius +1
shakakaka  Why sartorius is so lateral.. +

 +2  visit this page (nbme20#46)
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Hydronephrosis

Distention/dilation of renal pelvis and calyces A . Usually caused by urinary tract obstruction (eg, renal stones, severe BPH, congenital obstructions, cervical cancer, injury to ureter, pregnancy apparently); other causes include retroperitoneal fibrosis, vesicoureteral reflux. Dilation occurs proximal to site of pathology. Serum creatinine becomes elevated if obstruction is bilateral or if patient has an obstructed solitary kidney. Leads to compression and possible atrophy of renal cortex and medulla.

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 +3  visit this page (nbme20#16)
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Principle Sensory Nucleus of the Trigeminal is located in the Pons, as is the Motor Trigeminal Nucleus of the pons. This presentation is probably dealing more with the Principle Sensory Nucleus.

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 +5  visit this page (nbme20#43)
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Mullerian Agenesis (aka: Mayer-Rokitansky-Kuster-Hauser Syndrome)

Underdevelopment of the Mullerian system leading to congential absence of the vagina. Usually no cervix or uterus.

May present as 1° amenorrhea (due to a lack of uterine development) in females with fully developed 2° sexual characteristics. Functional ovaries allow for normal sexual characteristics and hormone levels.

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Subcomments ...

submitted by nosancuck(102), visit this page
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Yo dis B got NO INTERNAL FEMALE ORGANS

Why dat!???

We be lookin at someone with an SRY from dere Y chromie! Dey be a Y chromie Homie so they be makin some Testis Determinin Factor which I be sure makes some nice lil ANTI MULLERIAN FACTOR so dey aint got that Female Internal Tract u know what i be sayin

And since wimminz is da DEFAULT they stil be gettin dose pussy lips and breastes

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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 +17
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +6
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +6
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +32
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +7
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... +2
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +2
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/ +2
hyperfukus  i really hate haters this is awesome! +2
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +1
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +1


submitted by drdoom(1206), visit this page
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2,500 students ... but you find out during your initial screen that 500 already have the disease. So, strikeout those people. That leaves 2,000 students who don’t have the disease.

Over the course of 1 year, you discover 200 students developed the infection. Thus:

200 new cases / 2,000 people who didn’t have the disease when you started your study = 10 percent

Tricky, tricky NBME ...

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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
skonys  Must be Florida State University.... +
l0ud_minority  What if they got chlamydia again how would this change the numbers? +


submitted by usmleuser007(464), visit this page
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Just realized that renal cell carcinoma isn't the correct answer b/c it invaded the venous circulation and not the arterial. BP may not be affected as much. if RCC were the answer then then there would have been edema present and/or renal HTN.

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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 haliburton(224), visit this page
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link to cartoon diagram

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yotsubato  How is that NOT posterior to middle concha? bad question +11
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 +4
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +4


submitted by thomasalterman(181), visit this page
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My thought process was that post-partum bleeding is usually related to the uterus, and much of the pelvic viscera is supplied by branches of the internal iliac artery.

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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) +18
sympathetikey  @tsl - Thank you! +
step1soon  uworld Qid:11908 +1


submitted by hungrybox(1277), visit this page
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aka ampulla of Vater or the hepatopancreatic duct

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hungrybox  tripped me up cause I didn't know the names :( +17
sympathetikey  @hungrybox same +15
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 :'( :'( +8
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 +2


submitted by sympathetikey(1600), visit this page
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Self-limited disease often following a flu-like illness (eg, viral infection). May be hyperthyroid early in course, followed by hypothyroidism (permanent in ~15% of cases). Very tender thyroid is seen.

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sympathetikey  Short time course & tenderness was a tip for me. +14
rainlad  Aka de Quervain's thyroiditis +
kcyanide101  the quervian=pain. +1


submitted by karljeon(140), visit this page
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Vitamin E deficiency causes hemolytic anemia, acanthocytosis, muscle weakness, posterior column and spinocerebellar tract demyelination.

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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. +6
sympathetikey  @karljeon Intravascular hemolysis = LDH release from RBCs +4


submitted by neonem(629), visit this page
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Falling on outstretched hand: scaphoid is most common one to be fractured, lunate is most common to be dislocated. Lunate dislocation can cause acute carpal tunnel syndrome.

Think of the mnemonic "Straight Line To Pinky, Here Comes The Thumb" for the bones of the palm, drawing a football shape starting below the thumb MCP joint adjacent to the radius, then moving to your medial wrist, and then back to the thumb.

Scaphoid, lunate, triquetrum, pisiform, hamate, capitate, trapezoid, trapezium. The lunate looks like it's posteriorly dislocated here.

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sympathetikey  Yep. I didn't even look at the X-ray. +12
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 +11
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 +13
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. +
makingstrides  Another mnemonic, Some Lovers Tried Positions, That They Can't Handle +
ineedhelpwitmed  so long to pinky, here comes the thumb +
srmtn  in an X Ray (unless is marked) you can not know if is left or right. this is a lunate dislocation but actually is dorsal...even though they put in the stem that is anterior... please google "gilula lines" in order to fastly check a wrist X-ray and find a dislocation... also I think that a good clue when wrist trauma is: dislocation is usually lunate and necrosis is usually scaphoid. hope it helps +


submitted by ameanolacid(29), visit this page
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Couldn't be ALS b/c he had sensory involvement...ALS is distinctly only motor. Not Syringomyelia (which is upper extremities sensory then motor later on) bc I assumed by the wording that all 4 extremities were involved. Obv not Parkinsons, and not polio bc again, he has motor + sensory.

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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 lsmarshall(465), visit this page
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PCA stroke can cause "prosopagnosia" which is the inability to recognize familiar faces. Caused by bilateral lesions of visual association areas, which are situated in the inferior occipitotemporal cortex (fusiform gyrus). The ability to name parts of the face (e.g., nose, mouth) or identify individuals by other cues (e.g., clothing, voices) is left intact.

Without knowing that, remembering occipital lobe is involved in 'visual stuff' broadly, including image processing and this patient is having issues with understanding images should be enough to get to the answer.

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gonyyong  Lol I guessed it exactly because of that +8
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) +2
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 sympathetikey(1600), visit this page
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Pretty straightforward, but a good reminder that myelofibrosis can cause an enlarged spleen.

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sympathetikey  Due to extramedullary hematopoesis +31
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! +1
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +4
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 +3
limberry  @need_answers the bladder is intraperitoneal, not retro +
limberry  bladder is sub*peritoneal, sorry +


submitted by mousie(272), visit this page
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help with this one please.... is this because he has hyperTG AND Cholesterol AND chylomicrons.. only LL deficiency would explain all of these findings? I chose LDL R deficiency because I guess I though it would cause all of them to increase but is this type of deficiency only associated with high LDL?

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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. +12
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. +3
futurelatinadr  Pancreatitis was a huge clue for me to think of hyperchylomicronemia +1


submitted by jrod77(32), visit this page
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I think they might be describing angina...not sure. TXA2 is responsible for platelet aggregation,so it may be contributing to thrombosis, thus ischemia to the cardiac tissue.

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sympathetikey  Agreed. I'm pissed though because PGE2 mediates pain, which is why I picked it. +46
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 +8
youssefa  Went for PGE2 ... shit +
need_answers  I went for leukotriene B4, what the hell was I doing....SHIT +15
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. +12
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. +3
djtallahassee  ditto on the looked at it for 2 seconds and went PGE2 +1
veryhungrycaterpillar  My knee jerk reaction was to go with PGE2 for pain was well, but we must not forget that PGE2 is also a direct vasodilator. It also inhibits platelet aggregation. +
kungfupanda  I'm on a whole new level. i thought this might be an asthma attack and i choose LTB4 +2
an1  Intermittent chest pain does seem like angina. E2 does cause pain, but it also causes fEvEr. TXA2 inhibits platelets (unstable) AND increases vascular tone (prinzmetal) which makes it a better option. E2 increases uterine tone (check sketchy), not vascular so it can be chosen if they were to mention labor. +


submitted by sympathetikey(1600), visit this page
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I see what they're saying (this was my second choice) but at the same time I feel like a backup of blood would activate the baroreceptors and cause decreased sympathetic activity to the SA & AV node.

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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). +10
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +


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Why does methylation cause loss of resistance to GATC restriction endonuclease? Does this have to do with methylation of U to T?

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methylased  GATC related to methylase --> https://en.wikipedia.org/wiki/Dam_methylase +10
sympathetikey  Dam methylase, alright +2


submitted by aladar50(41), visit this page
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So there’s 100 residents, and the prevalence after 2 years is =10 at the beginning, +5 in the first year, +10 second year, and -3 that healed, for a total prevalence of 22 residents or 22/100=22 percent. Thus, prevalence = above the standard. For incidence, it’s 15 new cases out of 90 residents over the 2 years (100 total residents – 10 that already had ulcers), or 15 new ulcers per 180 patient⋅years. This would be 83.3 new ulcers per 1000 patient⋅years if you extrapolated it out -- basically (1000/180) * 15 -- thus, incidence = above the standard.

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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. +68
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. +4
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. +16
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 welpdedelp(270), visit this page
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No diet deficiency, the patient had excess carotene due to his diet

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sympathetikey  Would never have thought of that. Thanks +11
medschul  that's messed up dog +24
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" +8
davidw  β-Carotenes are present in dark-green and yellow vegetables. +1
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... +8
cbreland  I'm okay with missing this one +4
veryhungrycaterpillar  That was fucking stupid. I've known this excess carotene fact since 8th grade due to a friend getting it, but I still wouldn't have thought of it. I went with anemia, figured it had to be folic acid since B6 would have shown up sooner than four years. UGH. +
an1  Vitamin C def would not occur in vegans and would cause scurvy symptoms. Folic Acid is HIGH in green leafy vegetables, We can assume vegans eat a lot of veggies. As this causes a megaloblastic anemia, the sclera would be expected to be pale. IFN a + ribavirin is used for hep, which is ruled out because of the normal urine and stool, and lack of scleral icterus. B1 def presents with wernickes/ Korsakoff often with excess alcohol intake and hypoglycemia uncorrected after dextrose. B6 presents with sideroblastic anemia + peripheral neuropathy (remember that INH caused B6 to be excreted resulting in neuropathy). I got this wrong. Because who has time to go through every option and think it through, and who thought carrots would make the cut for this test. +1


submitted by sympathetikey(1600), visit this page
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Case Series

A group or series of case reports involving patients who were given similar treatment. Reports of case series usually contain detailed information about the individual patients. This includes demographic information (for example, age, gender, ethnic origin) and information on diagnosis, treatment, response to treatment, and follow-up after treatment.

In this question, it looks like they didn't really focus on the treatment part of it but otherwise, makes sense

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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 +21
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 ) +2
j44n  you dont need a control group in a cross sectional one so how do you differentiate that +
imatinib2412  The key to eliminate cross-sectional study here is the "During a 5-year period" part; cross-sectional studies you basically "take a picture" of a certain population and evaluate prevalence of disease/risk factors at that point in time +1


submitted by hayayah(1212), visit this page
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Patient has medullary carcinoma. Malignant proliferation of parafollicular "C" cells that produce calcitonin and have sheets of cells in an amyloid stroma.

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xxabi  Just to add - patient likely has MEN 2A or 2B with the presence of medullary thyroid cancer and pheochromocytoma +14
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(1212), visit this page
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Sensitivity tests are used for screening. Specificity tests are used for confirmation after positive screenings.

Sensitivity tests are used for seeing how many people truly have the disease. Specificity tests are for those who do not have the disease.

A highly sensitive test, when negative, rules OUT disease. A highly specific test, when positive, rules IN disease. So, a test with with low sensitivity cannot rule out a disease. A test with low specificity can't rule in disease.

The doctor and patient want to screen for colon cancer and rule it out. The doctor would want a test with high sensitivity to be able to do that. He knows that testing her stool for blood will not rule out the possibility of colon CA.

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sympathetikey  SeN Out (Snout) --> sensitive test; - test rules out SPec In (Specin) --> specific test; + test rules in +27
usmlecrasher  can anyone pls explain why it is not << potential false- positive results >> ??? +1
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? +1
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. +4
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. +2


submitted by strugglebus(189), visit this page
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As an edit: 108,001 people reported to have side effects when taking Hydrochlorothiazide. Among them, 25 people (0.02%) have Breast discharge

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neonem  I think the best way to answer this question was by process of elimination. +1
sympathetikey  That's some bullshit lol +9
karljeon  Haha I eliminated the answer by process of elimination. +25
medschul  I eliminated thiazides by process of elimination :( +3
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +2


submitted by strugglebus(189), visit this page
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So you know that 65% of the data will fall within 1SD of the mean. So if you subtract 100-65 you will get 35. Which means that about 16% will fall above and 16% will fall below 1 SD. They are asking for how many will fall above 1 SD. I'm sure there is a better way of doing this, but thats how I got it lol.

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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(189), visit this page
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The CI value contained 1, which means that its insignificant

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sympathetikey  Correct. Per first aid: "If the 95% CI for odds ratio or relative risk includes 1, H0 is not rejected." +2
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(155), visit this page
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Annular pancreas is the only answer that accounts for the bile in the vomit; of the choices, it is the only obstruction distal to where bile enters the GI tract.

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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(189), visit this page
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I chose this solely because it was so damn specific

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sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +5
karljeon  I didn't choose it because it was so damn specific. :( +48
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(401), visit this page
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A stretch injury during childbirth will result in damage to the external uretheral and anal sphincters and damage to the pudendal nerve (S2-S4). This can lead to decreased sensation in the perineal and genital area and fecal or urinary incontinence

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thepacksurvives  I think that there can also be a direct tear to the anal sphincter muscles +8
sympathetikey  A better answer choice would have been "damage to the nerves innervating the anal sphincter" but eh, ok. +22
nerdstewiegriffin  I it is due to actual tear of external and or internal anal sphincter Source uptodate +2
skonys  RIP... literally +2
namesthegame22  Episiotomy can damage the perineal body as well. +


submitted by monoloco(155), visit this page
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This is indirectly asking about peak bone density. That whole thing about weight-bearing exercises, eating right, yada yada, before and during that down-slope phase of life for bone density. All about reducing that 1% per year age-related bone density loss as best as we can. Level of activity is precisely like weight-bearing exercise. (Consider: no activity, bed-ridden -- say goodbye to your bones; highly active, runs every other day -- good amount of weight-bearing / stress to induce remodeling and maintain integrity of the bones.)

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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? +19
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? +4
j123  I'd put money on a fat baby who doesn't exercise to heal faster than my 95 yo grandpa who rides his stationary bike 2 hrs per day... lol +1
stresssweat  In that same train of thought, another modifiable risk factor for fracture would be levels of calcium and vitamin D intake throughout childhood. I crossed these out because they were essentially the same thing so obviously neither could be right, but aside from that - what would be the actual reason those were wrong? +


submitted by meningitis(643), visit this page
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When standing up, the body normally activates sympathetic system to avoid orthostatic hypotension.

But since there is now an additive effect of the pheochromocytoma adrenergics, it will lead to a hypertension

(i.e: Double vasoconstriction = Pheo adrenergics + Sympathetic system)

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sympathetikey  Brilliant. +6
medschul  Would pheo have a normal resting BP though? +16
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. +10
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +2
nala_ula  No problem! Thank you for all your contributions throughout this page! +2
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 +2
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 +
jakelong377  It’s not about being stressed infront of doctor. When u stand sympathetics activate to prevent orthostatic hypotension, to counter it adrenal medulla released catecholamines so much so that pheochromocytoma patients would appears with flushed skin n such +


submitted by mrmassador(12), visit this page
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I think the point of the question is to recognize that this is a mitochondrial disease (mother and maternal grandmother were affected). Produces wide range of effects, but muscle weakness and some neurologic deficits stood out to me. Also this: https://ghr.nlm.nih.gov/gene/MT-TL1#conditions

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sympathetikey  Yes, but doesn't that mean maternal transmission? Men can have these diseases too, they just won't pass them on. +32


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