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Comments ...

 +4  (nbme21#26)

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.

thisisfine   Same - the bleeding thing pushed me over to psoriasis as well. Oops.
temmy  the distribution of the other lesions, forearm, face, ear, scalp..is not characteristic for psoriasis.
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
hyperfukus  oh last thing psoriasis itches! they said no itching

 +7  (nbme21#4)

• Per Protocol - Only include patients in the results who followed the protocol

• As treated - Data wise, only treat the subjects as they were treated (ex - if experimental patient does what the control patients are supposed to do, move that experimental patient to the control group

• Intention to treat - Include all patients in the groups they were originally randomized to


 +0  (nbme21#4) • Per Protocol - Only include patients in the results who followed the protocol • As treated - Data wise, only treat the subjects as they were treated (ex - if experimental patient does what the control patients are supposed to do, move that experimental patient to the control group

Intention to treat - Include all patients in the groups they were originally randomized to



 +1  (nbme21#34)

Inferior oblique = helps you look up & in.

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

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
emmy2k21  Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :(
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.
chandlerbas  bam! dr_jan_itor just cleaned up that confusion

 +2  (nbme18#32)

Person probably has Irritable Bowel Syndrome. Regardless, it seems like they're trying to treat symptoms with an oipoid anti-diarrheal like loperamide.


 +0  (nbme18#31)

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.

sympathetikey  Short time course & tenderness was a tip for me.

 +0  (nbme18#22)

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


 +1  (nbme18#5)

Appears to be fibrin deposition secondary to bacterial peritonitis.


 +0  (nbme18#41)

Guillain Barre is T-cell mediated destruction of myelinated axons. Generally presents with a rapid onset following a viral / bacterial illness with ascending paralysis.


 +0  (nbme18#42)
• Pompe Disease (Type 2)
    ○ Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase)
    ○ Buildup of 1,6 linkages
    ○ Presentation:
        § 1. Cardiomegaly
sympathetikey  *1,4 glucosidase

 +3  (nbme18#4)

Histone acetylation allows for relaxation of the DNA so that transcription can proceed. All trans retinoic acid causes the granulocytes in APML to further mature, which requires DNA transcription / translation.


yb_26  @at0xibolic, I think you won this competition on finding better picture lol thanks

 +4  (nbme24#37)

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.


 +2  (nbme24#23)

I just tried to think of what's released by the Adrenal Medulla (Epinephrine). PNMT is the only choice that made sense.


 +10  (nbme24#38)

Would've been nice if they told you "2nd intercostal space" on left or right...smh


 +9  (nbme24#33)

Everyone who got this question right is a cop. ༼⌐■ل͟■༽


 +2  (nbme24#49)

Pretty straightforward, but a good reminder that myelofibrosis can cause an enlarged spleen.

sympathetikey  Due to extramedullary hematopoesis
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  (nbme24#19)

Buzzword: excessive tearing

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


 +4  (nbme24#24)

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


 +1  (nbme23#28)

Keys were the:

-Glucosuria

-Phosphaturia

-Amino aciduria

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

lamhtu  To be even clearer, this sounds like **Fanconi syndrome, which has lead to Type II RTA**
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

 +6  (nbme23#42)

Classic homocystinuria.

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


 +6  (nbme23#21)

Hard to see due to poor picture quality, but based on what I could see, it seems like a spontaneous pneumothorax to me (based on the lack of lung marking on the left compared to the right side).

Therefore, since the lung is deflated, all you would have in the left side of the open cavity, which would make the left side hyperressonant.

sugaplum  FA 2019 pg667

 +11  (nbme23#30)

Biggest clue was that there was no time frame given. Therefore, this seems to be a "slice in time" study, which lines up with cross sectional study.

tamey  and also among the other answer choices cross sectional study is the only one thats used for population study
paulkarr  Damn, epi at it again...

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

 +3  (nbme23#50)

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.

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

 +3  (nbme23#16)

Dexamethosone suppresses ACTH = Pituitary Adenoma Dexamethosone fails to suppress ACTH = Ectopic ATCH (ex - Small Cell Lung Cancer)

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

 +4  (nbme23#6)

Seminoma is the most common testicular tumor. It's a germ cell tumor. Commonly see "fried egg cells".

motherfucker2  If it was a woman would be a dysgerminoma. Seminomas have excellent prognosis and highly radiosensitive. MCC testicular tumor

 +5  (nbme23#27)

Any time you see fixed wide splitting of S2, smash ASD.

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

 +2  (nbme23#21)

Per FA (pg. 636): Concerning breast cancer...

"Amplification/overexpression of estrogen/ progesterone receptors or c-erbB2 (HER2, an EGF receptor) is common; ER ⊝, PR ⊝, and HER2/neu ⊝ form more aggressive."

sympathetikey  FA 2019
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.
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

 +3  (nbme23#49)

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

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
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.

 +1  (nbme23#7)

Mad at myself for changing my answer.

Faulty logic made me wonder if hitting your head would caused increased ICP so, like a cushing ulcer, you would get increased Vagus nerve activity and maybe bradycardia + hypotension. But I guess the RAAS system would have counteracted that and caused vasoconstriction over 24 hours, so Hypovolemic shock is definitely the best choice.

Always should go with the obvious answer :)

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.
uslme123  The Cushing reflex leads to bradycardia!
purdude  Wait I'm confused. I thought hypovolemic shock leads to an increased SVR?
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.
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  (nbme23#16)

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"

littletreetrunk  I think this makes total sense, but how does it not ALSO stop fast axonal transport?
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."
yotsubato  axonal transport is mediated by kinesin and dynein. Microtubule toxins like vincristine block these

 +1  (nbme23#25)

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


 +6  (nbme23#32)

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.


 +3  (nbme23#22)

Believe this question is referring to Visceral Leishmaniasis.

gabeb71  The give away is the Fever, Pancytopenia, and Hepatosplenomegaly after being bitten by an insect and developing the sore.

 +3  (nbme23#6)

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.

ls3076  how can we actually be expected to know vaccination schedules... there must be some other reason the answer is correct

 +2  (nbme23#2)

One of the side effects of Cyclophosphamide is myelosuppression.

See full list of side effects below:

Myelosuppression; SIADH; Fanconi syndrome (ifosfamide); hemorrhagic cystitis and bladder cancer, prevented with mesna (sulfhydryl group of mesna binds toxic metabolites) and adequate hydration.


 +1  (nbme20#49)

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).

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/
hungrybox  such a dumb question wtf

 +6  (nbme20#26)

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


 +2  (nbme20#46)

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.


 +2  (nbme20#14)

I believe the biopsy description of "small basophillic cells forming tumor islands" is describing the peripheral palisading that is classically seen in Basal cell carcinoma.


 +3  (nbme20#27)

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

sympathetikey  Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/case-series
ngman  I think another factor is that in case series studies there is no control group vs case-control, cohort...ect

 +4  (nbme20#35)

As stated below, the Left crus cerebri was damaged (see what it should normally look like below). This contains the corticospinal tract. Since the corticospinal tract decusates at the medulla, below the midbrain section we're looking at, you would see Contralateral (Right) Spastic Hemiparesis

sympathetikey  http://what-when-how.com/wp-content/uploads/2012/04/tmp15F11_thumb.jpg
hello  What identifies that a cross-section is medulla vs midbrain vs pons?
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.
hello  @kernicterusthefrog Thank you.

 +2  (nbme20#23)

CD4+ cells activate B-cells which form follicles and cause enlargement of lymph nodes. Therefore, in an AIDS patient, to enlarge the lymph nodes, the CD4+ dysfunction must be resolved.

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
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

 +2  (nbme20#16)

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.


 +1  (nbme20#7)

In addition to PTH = osteoclast activity = increased calcium, this person could also be exhibiting symptoms of MEN1.


 +5  (nbme20#25)

Mutations in MT-TL1 (Mitochondrially encoded tRNA leucine 1)

A common mutation is A3243G. Can result in multiple mitochondrial deficiencies and associated disorders. It is associated with:

  • Mitochondrial encephalomyopathy
  • Lactic acidosis
  • Stroke-like episodes (MELAS)

MELAS is a rare mitochondrial disorder known to affect many parts of the body, especially the nervous system and the brain. Symptoms of MELAS include:

  • Recurrent severe headaches
  • Muscle weakness (myopathy)
  • Hearing loss
  • Stroke-like episodes with a loss of consciousness, seizures, and other problems affecting the nervous system.

Source: https://en.wikipedia.org/wiki/MT-TL1


 +0  (nbme20#43)

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.


 +2  (nbme20#35)

Spleen so huge -- look like this girl has 2 livers.


 +4  (nbme20#21)

Choice A. would have been correct if this patient was immunocompromised. Per First Aid, "If CD4 <100, Bartonella...Findings: Neutrophilic Inflammation.

However, as this patient has a competent immune system, buzz words are stellate necrotizing granulomas.

yotsubato  Everyones choice A is different.
sugaplum  they mean- Diffuse neutrophil infiltration
macrohphage95  what does stellate necrotizng granuloma means ?
krisgsxr600  always with the details! losing dumb points :(
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?




Subcomments ...

submitted by vi_capsule(8),

HTN emergency, Sodium Nitroprusside. Unlike hydralazine a balanced vasodilator (vein = arteriol)

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 +2  


submitted by haliburton(92),

EF2 is translational elogation factor 2, which is necessary for protein synthesis.

sympathetikey  I. Am. So. DUMB. +8  
nala_ula  same :( +1  


submitted by mcl(232),

PCOS is associated with abnormal production of sex steroids, including dysfunction of estrogen production and progesterone. Chronically elevated levels of estrogen can cause endometrial hyperplasia.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3917599/

meningitis  Why isnt it endometriosis? Could someone help me out on this? +  
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. +3  
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 +  


It said it was fatal to males in utero, and the question asked about live born offspring. Since the males aren’t being born in the first place, I said 50% females and 0% males.

hungrybox  fuck i got baited +8  
jcrll  "live-born offspring" ← baited +4  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +1  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  


submitted by nosancuck(42),

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

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 +11  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +3  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +2  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +1  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +2  
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... +  
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/ +  
hyperfukus  i really hate haters this is awesome! +  


submitted by nosancuck(42),

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

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 +11  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +3  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +2  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +1  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +2  
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... +  
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/ +  
hyperfukus  i really hate haters this is awesome! +  


It’s acute alcohol consumption so fatty change more likely. Cellular swelling indicates alcoholic hepatitis which requires chronic alcohol consumption (See FA 2019 pg 385). At least that’s the logic I used to pick fatty change.

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. +11  
nc1992  I think it's just a bad question. It should be "on weekends" +5  
uslme123  https://webpath.med.utah.edu/LIVEHTML/LIVER145.html +3  
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! +  


submitted by neonem(278),

Morphine is a mu opioid agonist - one adverse effect of opioids is mast cell degranulation that is IgE-independent. Release of histamine is akin to an anaphylactic reaction --> pruritis, etc.

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) +  
temmy  it was a u world question +  


submitted by drdoom(232),

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 ...

sympathetikey  Ah, I see. Thank you! +  
niboonsh  Im mad at how simple this question actually is +2  
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 +1  


submitted by hungrybox(256),

Dysplastic nevi are a precursor to melanoma. They have irregular, "dysplastic" borders. Remember the "B" in ABCD stands for irregular Borders. Nevus means mole.

Other answers:

  • acanthosis nigricans - Darkening of skin associated with Type II diabetes mellitus

  • basal cell carcinoma of skin - Rarely, if ever metastasizes. Commonly affects upper lip.

  • blue nevus - Blue-colored type of common mole. Benign.

  • pigmented seborrheic keratosis - "Stuck on" appearance. Mostly benign. Affects older people.

  • (Note - you usually see only one. If multiple seborrheic keratoses are seen, it indicates a GI malignancy - aka "Leser-Trélat sign)
usmleuser007  correction ~ BCC affects the lower lip more than the upper +  
sympathetikey  Pathoma says upper lip, good sir +6  
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 +2  


submitted by usmleuser007(135),

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.

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? +  


submitted by cantaloupe5(42),

Recurrent kidney stones should include hyperparathyroidism on your differential, couple that with gastrinoma and you’re looking at MEN 1. Lipomas are also associated with MEN 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. +  


yotsubato  How is that NOT posterior to middle concha? bad question +3  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +1  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +1  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +  


submitted by yo(26),

they're talking about a splenorenal shunt procedure

https://my.clevelandclinic.org/health/treatments/4950-distal-splenorenal-shunt

hungrybox  be honest did u know that before looking it up +3  
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. +3  
sympathetikey  Relax @meningitis. Hungry's just messin :) +3  
sbryant6  Looks like somebody needs an enema to get that stick out. +  
chandlerbas  ya'll are too TP/(TP+FN) lol +  


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

neonem  This sounds like a case of acute endometritis. In any case, uterus is supplied by uterine artery (branch of internal iliac artery) with collateral flow from ovarian artery (comes right off aorta). I don't think there are any branches of external iliac artery into the pelvis; it becomes femoral artery once it passes under inguinal ligament. +2  
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) +7  
sympathetikey  @tsl - Thank you! +  
step1soon  uworld Qid:11908 +  


submitted by dr.xx(44),

Among the most prevalent hematologic abnormalities in patients with rheumatologic disorders are the anemia of chronic disease (ACD), a mild anemia that is generally asymptomatic, and iron deficiency anemia.

In iron-deficiency anemia, the TIBC would higher than 400–450 mcg/dL because stores would be low.

Patients with RA occasionally have concurrent iron deficiency anemia and ACD. When this occurs, the hemoglobin level usually drops to below 9.5 g/dL, and the MCV is less than 80.

https://www.uptodate.com/contents/hematologic-manifestations-of-rheumatoid-arthritis

sympathetikey  Got the right answer too, but man, that whole "1 month after starting therapy" almost threw me off. +  


submitted by yotsubato(312),

She has Bernard Soulier Disease page 419 of first aid 2019

sympathetikey  That's a genetic deficiency of GP1b -- not antibody related +2  
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(256),

aka ampulla of Vater or the hepatopancreatic duct

hungrybox  tripped me up cause I didn't know the names :( +5  
sympathetikey  @hungrybox same +2  
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 :'( :'( +  


submitted by drdoom(232),

Vasoconstriction (narrowing of a tube) will cause the flow rate to increase through that tube, which decreases radial/outward pressure. The faster a fluid moves through a tube, the less “outward” force it exerts. (This is known as the Venturi effect.)

hungrybox  not seeing how this is relevant +1  
sympathetikey  He's showing how A & B are incorrect @hungrybox +2  


submitted by sympathetikey(363),

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.

sympathetikey  Short time course & tenderness was a tip for me. +1  


submitted by sympathetikey(363),
• Pompe Disease (Type 2)
    ○ Lack of - Lysosomal Debranching Enzyme (α-1,6 Glucosidase)
    ○ Buildup of 1,6 linkages
    ○ Presentation:
        § 1. Cardiomegaly
sympathetikey  *1,4 glucosidase +  


submitted by karljeon(30),

Vitamin E deficiency causes hemolytic anemia, acanthocytosis, muscle weakness, posterior column and spinocerebellar tract demyelination.

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. +3  
sympathetikey  @karljeon Intravascular hemolysis = LDH release from RBCs +1  


Why is the answer “granulation tissue”? I thought after 14 days you have a fully formed scar.

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. +3  
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. +  
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. +  
yotsubato  Thats cause the NBME exam writers read FA, then make questions not fit in with FA +1  
trichotillomaniac  This fits the timeline laid out in Pathoma! 1-3 wks = granulation tissue with plump fibroblasts, collagen, and blood vessels +3  


submitted by neonem(278),

These are gout crystals. I suppose the best way to differentiate this case from pseudogout is that the crystals are sharp & needle-shaped and not rhomboid-shaped.

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. +6  
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +  


submitted by seagull(467),

at BMI 15 not only has she never had a period but she never had a meal.

sympathetikey  You're on fire man lol +  
monkey  How the fuck is it not related to anorexia nervosa is beyond me. +  


submitted by seagull(467),

The semantics of this question made me vomit blood.

One day a patient will look me in the eyes and ask, "Where are tripetides broken down?" I will smile at them and say, "the intestinal mucosa and not the duodenum." They'll smile back and I'll walk away and think of this moment as I jump from the window.

sympathetikey  Too real. +2  
mcl  how do i upvote multiple times +7  
trichotillomaniac  I made an account solely so I could upvote this. +6  
dragon3  ty for the chuckle +3  
cinnapie  @trichotillomaniac Same +3  


submitted by m-ice(135),

The patient needs medical attention immediately, which eliminates obtaining a court order, or transferring her. A nurse does not have the same training and qualifications as a physician, so it would be inappropriate to ask them to examine the patient. Asking the hospital chaplain again could be inappropriate, and would take more time. Therefore, the best option among those given is to ask the patient if she will allow with her husband present.

sympathetikey  Garbage question. +19  
masonkingcobra  So two men is better than one apparently +5  
zoggybiscuits  GarBAGE! ? +  
bigjimbo  gárbágé +  
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? +1  
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 +1  
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. +5  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +6  
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 +1  
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 +  
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. +  


submitted by neonem(278),

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.

sympathetikey  Yep. I didn't even look at the X-ray. +1  
dr.xx  loonies love lunate +1  
wes79  she landed on her "right hand", but the X-ray is showing a left hand?? +  
wes79  i legit have no idea whats going on in that xray lol +2  
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. +  
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. +1  
doctorevil  She Looks Too Pretty, Try To Catch Her is a mnemonic that works for me. +  
niboonsh  Some Lovers Try Positions That They Cant Handle +1  


Thank you NBME for the high quality pictures. It makes these exams stress free and enjoyable.

sympathetikey  Feels bad man. +2  
zoggybiscuits  Those Sclera sure look blue. wow. +  
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. +2  


submitted by neonem(278),

This is acute hemolytic transfusion reaction, a type II hypersensitivity where pre-formed IgM antibodies bind to incompatible ABO antigens on donor RBCs, which causes intravascular hemolysis. Rh incompatibility, like colonelred_ said, comes more into play with Rh-compatibility of pregnancy and it is due to IgG antibodies, which more often cause extravascular hemolysis since splenic macrophages have those Fc-gamma-R receptors to bind whatever IgG has caught. Extravascular doesn't cause that hypotension, fever, flank pain associated with hemoglobinuria since the macrophages hold on to the degraded RBCs and convert it to biliverdin, which can safely be excreted by the liver.

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 .... +1  
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. +2  
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! +2  


submitted by ameanolacid(12),

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.

sympathetikey  Probably in part due to early age presentation, but I hear you +1  
wowo  FA2019 p518 - process of elim for other spinal cord lesions +  


submitted by sattanki(32),

Muscle pain + periorbital edema is a classic presentation for trichonella spiralis. Best diagnosis for this is a muscle biopsy, as the wormy likes to hangout within the muscles.

sympathetikey  That's what you get for killing polar bears. +15  
dr.xx  That's what you get for not cooking them well. +1  
charcot_bouchard  Theres nothing called "well cooked polar bear meat" +1  


submitted by lsmarshall(216),

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.

gonyyong  Lol I guessed it exactly because of that +1  
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! +1  


submitted by lsmarshall(216),

"Desmosome (Macula adherens) - A cell-to-cell connection that provides structural support with intermediate filaments, particularly in tissues that undergo mechanical stress (e.g., skin, gastric tissue, bladder). Connects keratinocytes in the stratum spinosum of the epidermis." - AMBOSS

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. +9  
roygbiv  I'm confused because I also know that S. aureus cleaves desmoglein in the stratum granulosum, so why is it specifically this answer? +  
duat98  desomosomes connects cells to cells. hemidesmosome connects cells to basement membrane. +  


Why is it not ovarian follicle cells? I thought the female analog of Sertoli and Leydig is theca/granulosa cells.

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +3  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +11  
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 +6  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +3  
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. +4  
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? +1  
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" +1  
youssefa  Hahahahaha ya'll just bored +2  
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 +1  
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? +  
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 +1  
noplanb  Wait... I might actually never forget this now lol +  
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! +  


submitted by sympathetikey(363),

Pretty straightforward, but a good reminder that myelofibrosis can cause an enlarged spleen.

sympathetikey  Due to extramedullary hematopoesis +3  
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 ?? +  


submitted by lsmarshall(216),

Patient has Spina bifida occulta which is a neural tube defect (failure of fusion of the neuropores). Sclerotomes are the part of each somite in a vertebrate embryo giving rise to bone or other skeletal tissue. Since a part of this patient's spina bifida included "abscense of spinous process" then a sclerotome was involved. Knowing that neural tube defects are an issue with fusion should be enough to get to the right answer.

If the notochord failed to develop then the entire CNS would not develop as the notochord induces formation of neural plate.

If the neural tube failed to develop then the whole CNS would not have developed.

Yolk sac is irrelevant to this patient.

When neural crest cell it has different outcomes in different tissues. Failure of neural crest to migrate in heart can cause Transposition of great vessels, Tetralogy of Fallot, or Persistent truncus arteriosus. Failure of neural crests to migrate in GI can cause Hirschsprung disease (congenital megacolon). Treacher Collins Syndrome can occur when neural crest cells fail to migrate into 1st pharyngeal arch. Neural tube defects has nothing to do with failure of neural crest migration though.

sympathetikey  Exactly. I knew it had to due with fusion of the neuropores but had never heard of sclerotomes. Thanks for the explanation. +1  


submitted by sheesher(0),

I'm assuming that because bicarbonate is decreased, this has to be metabolic acidosis caused by acetazolamide? Missed this question because I was looking for metabolic acidosis (increased bicarbonate) caused by a loop diruetic...

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. +4  
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). +4  
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-]** +1  


submitted by seagull(467),

"why don't you stop what you're doing because it's ridiculous". --actual answer

sympathetikey  Mam--mam. Put down the egg, mam. +1  
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. +  


submitted by mousie(88),

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?

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. +4  
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 +7  
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. +  


Patient is current breast-fed, so we can eliminate fructose (fructose is found in honey and fruits and some formula, but not in breast milk). Patient has reducing substances but no glucose in the urine, so he must some non-glucose sugar. My differential for reducing non-glucose sugars in the urine is disorders fructose metabolism or galactose metabolism. We have eliminated fructose, so that leaves us with galactokinase deficiency or classic galactosemia.

sympathetikey  & Galactokinase deficiency would be much milder. +3  
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). +  


submitted by seagull(467),

i'm still convinced this is irritable bowel syndrome. Change my mind.

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. +  
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. +  
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 +4  
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. +4  


submitted by jrod77(13),

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.

sympathetikey  Agreed. I'm pissed though because PGE2 mediates pain, which is why I picked it. +8  
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 +  
vik  hahah, seems like all in same boat like me +  
yb_26  thromboxane A2 is also vasoconstrictor, so my thoughts were about vasospastic angina +  
shriya goyal  same I went for pgE2 ... I M PISSED +  
shriya goyal  same I went for pgE2 ... I M PISSED +  
youssefa  Went for PGE2 ... shit +  
need_answers  I went for leukotriene B4, what the hell was I doing....SHIT +1  
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. +1  
ususmle  same here I M PISSED PGE2 +  
krewfoo99  Maybe PGE2 isint the answer because it mediates pain and fever during episodes of acute inflammation? Thus making TXA2 more likely. +  


A normoblast is an immature RBC, so it's elevated in states of increased hematopoiesis.

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +12  
someduck3  The term "Normoblast" isn't even in first aid. +10  
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +1  
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. +3  


submitted by ferrero(19),

A very similar question I have seen in Qbanks will ask why a patient with right heart failure does not develop edema and the answer is increased lymphatic drainage. I got this question wrong originally because I answered along this line of reasoning but I think in this case it all has to do with WHERE the extra pressure is coming from. In this question the pt has diastolic hypertension so you can think about the pressure as coming "forward" so constricting precapillary sphincters can prevent an increase in pressure in the capillary bed. However for right heart failure this extra fluid is coming from the OPPOSITE direction (backwards from the right heart) and constricting precapillary sphincters can do nothing (on opposite side of capillary bed) - the only way to prevent edema is to increase lymphatic drainage.

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)? +11  
mousie  Great explanation, I chose lymphatic drainage for the same reasoning (similar Q on different bank) +1  
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. +14  
cr  the main difference between the 2 cases is that in this case the patient has high BP +  
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. +  
hello  @ferrero what are you talking about? lymphatic drainage is the wrong answer... +  
hello  ok never mind. i got it. hard to understand b/c it was a big block of text. +  
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." +  


submitted by seagull(467),

What a terrible picture. They they covered up part of it with lines. WTF

sympathetikey  Agreed. +  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +  
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 +  
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? +1  
catch-22  You're looking at the ventral aspect of the brainstem. +3  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +1  
hello  which letter is CN IX in this diagram? +  


submitted by seagull(467),

This patient is tripping balls. Better do a drug screen which seems obvious.

sympathetikey  When the answer is so obvious that you pick a stupid answer instead of it. DOH +5  
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 +2  
yotsubato  @sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that. +  
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 +  


submitted by seagull(467),

This is a panic attack. Hyperventilation drops pCO2 leading to a respiratory alkalosis. po2 is relatively unaffected (don't ask me how?)

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. +4  
imnotarobotbut  lmao i'm so freaking dumb i thought she was having alcohol withdrawals because it was relieved by alcohol +  
soph  Maybe Po2 is unaffected bc its perfusion (blood) limited not difusion limited (under normal circumstances). +  
charcot_bouchard  PErioral tingling- due to transient hypocalcemia induced by resp alkalosis. +  


sympathetikey  Makes total sense looking back. Just didn't know that was a thing :) +3  
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 +7  


submitted by sympathetikey(363),

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.

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). +6  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


The patient has ATN secondary to renal ischemia. Due to tubular necorsis, the patient will have an elevated FeNa. The patient's urine will also be dilute, but this will be reflected by the low urine osmolality, not the FeNa

mousie  Hypotension can also cause pre renal azotemia with a FENa <1%.... How do you know this is ischemic ATN and not hypotension induced Prerenal Azotemia? +1  
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. +  
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. +11  
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! +6  
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? +  


submitted by sympathetikey(363),

Dexamethosone suppresses ACTH = Pituitary Adenoma Dexamethosone fails to suppress ACTH = Ectopic ATCH (ex - Small Cell Lung Cancer)

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 +1  
bigjimbo  Low ACTH = adrenal adenoma High ACTH, suppressible = Pituatary adenoma High ACTH, non-suppressible = SCLC +  


submitted by sympathetikey(363),

Per FA (pg. 636): Concerning breast cancer...

"Amplification/overexpression of estrogen/ progesterone receptors or c-erbB2 (HER2, an EGF receptor) is common; ER ⊝, PR ⊝, and HER2/neu ⊝ form more aggressive."

sympathetikey  FA 2019 +1  
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 +1  


submitted by welpdedelp(79),

I chose this b/c its the most common pathogen for skin infections

seagull  same here +2  
sympathetikey  Some bowlsheet +3  


submitted by welpdedelp(79),

It was the only peripheral lung cancer, its also more common in women. Metastasis would have shown multiple lesions

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. +2  
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. +  


submitted by sajaqua1(229),

Critical points for this question: 5 year old boy, immunosuppressed because of chemotherapy, 2 day history of fever, cough, shortness of breath, febrile (101.8 F), respirations 46/min, with cyanosis and generalized vesicular rash. Extensive nodular infiltration.

Of the options listed only measles and VZV give a rash. A rash from measles usually starts rostrally and descends caudally, and is flat and erythematous. By contrast, VZV (chickenpox) presents with generalized rash that quickly transitions from macular to papular then to vesicular.

sympathetikey  Good call. +1  
imnotarobotbut  Also, VZV causes pneumonia (what this patient probably had) and encephalopathy in the immunocompromised. +2  
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! +  
jboud86  If anyone wants to refresh info on Vaicella-Zoster virus, page 165 in FA 2019. +  


submitted by mousie(88),

Why no sweating? I mean I get Ecstasy is probably the drug of choice before an all night dance party (lol) but don't understand why there would be cold extremities and no sweating when is FA it says hyperthermia and rhabdo????

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. +2  
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. +3  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +3  
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 +4  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +  
sbryant6  @fulminant_life FALSE. KETAMINE CAUSES CARDIOVASCULAR STIMULATION. +1  
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/ +  


submitted by step420(19),

Ritonavir inhibits CYP450! So you can use it to boost the concentration of the other Protease inhibitors by preventing their metabolism by CYP450!

mousie  who knew +1  
sympathetikey  Right on (thanks sketchy) +3  
mguan1993  MAGIC RACKS is a good mnemonic ive heard for 450 inhibitors (macrolides, amiodarone, grapefruit, cimetidine, RITONAVIR, alcohol (chronic), cipro, ketoconazole, sulfa +1  
criovoly  "CRACK AMIGOS" Cimetidine Ritonavir Amiodarone Ciprofloxacion Ketoconazole Acute alcoholism Macrolides Isoniasid Grapefruit juice Omeprazole Sulfonamides +2  


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

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


submitted by lilamk(5),

I made a lucky guess and chose this but I don’t think for the right reasons. I thought maybe he has BTK deficiency/Bruton’s Agammaglobinemia. But, now that I am going over it I wasn’t sure. Would that show a normal leukocyte differential? Is it CVID? Didn’t think CVID would have absent germinal centers in lymph nodes. What else could this be?

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 +1  
sympathetikey  What @lispected said. +  


I thought that the primary sympathetic innervation to the heart was through T1-T4. Why would stimulation of this ganglion not affect skin vessels in the upper limb?

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. +1  
sympathetikey  Got this wrong too. I think upper extremity skin vasodilation (which I picked) is probably more due to local metabolites. +  


submitted by aladar50(19),

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.

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. +7  
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. +1  
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 :| +1  
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. +4  
sympathetikey  @zelderonmorningstar I thought the same exact thing. Had the right logic, but then just put the backwards answer. +2  
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. +6  


submitted by beeip(65),

The best I can understand, they're describing endometrial hyperplasia, a result of excess estrogen, a steroid hormone that translocates to the nucleus and binds its transcription factor.

mousie  My exact thinking also! +3  
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 +1  
eve1000  Could this be due to the PTEN gene being linked to endometrial hyperplasia? +  


The most important hints to the question are as follows, with #2 being the most specific:

1) patient reports pain with overhead motion and reports recurrent overhead motion during work. Overhead motion can damage the supraspinatus muscle due to impingement by the acromion.

2) Pain is worst with internal rotation of the shoulder - this is consistent with the findings of the empty-can test, which indicates a supraspinatus injury.

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 +  
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 +7  
ls3076  why would injury to supraspinatus cause weakness with internal rotation though? +5  
targetusmle  yeah coz of that i picked subscapularis +1  
maddy1994  ya the whole question pointed to supraspinatus ...but last line internal rotation made me pick subscapularis +2  
darthskywalker306  I went for Trapezius. That shoulder flexion thing was a big distraction. Silly me. +  


submitted by mousie(88),

A hemangioma is a type of benign (non-cancerous) tumor in infants. This abnormal cluster of small blood vessels appears on or under the skin, typically within one to three weeks after birth. - www.childrenshospital.org Hemangioma is a BV/capillary birthmark

sympathetikey  Probably a Strawberry Hemangioma since she's a baby +2  
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. +  


submitted by welpdedelp(79),

No diet deficiency, the patient had excess carotene due to his diet

sympathetikey  Would never have thought of that. Thanks +3  
medschul  that's messed up dog +3  
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" +2  
davidw  β-Carotenes are present in dark-green and yellow vegetables. +  
hyperfukus  ohhhh hellllll no +  
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... +  


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." +1  
smc213  This video helps https://www.youtube.com/watch?v=Kps3VzbykFQ +4  
rio19111  Thx smc213, really helped. +1  


submitted by sympathetikey(363),

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

sympathetikey  Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/case-series +1  
ngman  I think another factor is that in case series studies there is no control group vs case-control, cohort...ect +5  


submitted by hayayah(449),

Iron overdose is a cause of a high anion gap metabolic acidosis.

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/ +10  
sympathetikey  None of the other choices were even metabolic acidosis. They threw us a bone with this one. +1  
imnotarobotbut  Don't changes in bicarb take a few days? How did his bicarb drop down to 8 in 12 hours? +  
charcot_bouchard  its met acidsis. not compensation +1  


submitted by louisville(7),

Methylene-blue stained fecal smear reveled numerous neutrophils (but not any organisms). Shigella is colorless when stained with methylene blue; E coli stains blue with methylene blue because it ferments lactose.

sympathetikey  E. coli stains green (just fyi) otherwise, perfect. +3  
chandlerbas  only E coli stains green, all other lactose fermenters stain purple/black (just fyi) otherwise, perfect. ;) FA144 bottom +  


submitted by hayayah(449),

Patient has medullary carcinoma. Malignant proliferation of parafollicular "C" cells that produce calcitonin and have sheets of cells in an amyloid stroma.

xxabi  Just to add - patient likely has MEN 2A or 2B with the presence of medullary thyroid cancer and pheochromocytoma +2  
sympathetikey  @xxabi Was going to say the same thing. +  


submitted by hayayah(449),

Familial adenomatous polyposis is an autosomal dominant mutation. Thousands of polyps arise starting after puberty; pancolonic; always involves rectum. Prophylactic colectomy or else 100% progress to CRC.

Autosomal dominant diseases have, on average, 50% chance of being passed down to offspring.

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. +1  
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" +1  


submitted by hayayah(449),

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.

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


submitted by step420(19),

Other kidney Hypertrophies due to increased stress --> not hyperplasia bc not cancerous

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. +8  
johnthurtjr  FTR Pathoma Ch 1 Dr. Sattar mentions hyperplasia is generally the pathway to cancer, with some exceptions like the prostate and BPH. +2  
sympathetikey  Tubular hypertrophy is the natural compensation post renal transplant. Just one of those things you have to know, unfortunately. +1  
charcot_bouchard  Isnt Kidney a labile a tissue & thus should undergo both. This ques is dipshit +  


submitted by ark110(1),

But what is the difference between option A and option C (132; 4.9; 90; 35)

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. +  
ergogenic22  RAAS increases from volume loss, and thus more aldosterone leads to low K+ +  
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. +2  


submitted by hayayah(449),

Notice, the stem says "precorsors in the skin"

D3 (cholecalciferol) from exposure of skin (stratum basale) to sun, ingestion of fish, milk, plants.

D2 (ergocalciferol) from ingestion of plants, fungi, yeasts.

Both converted to 25-OH D3 (storage form) in liver and to the active form 1,25-(OH)2 D3 (calcitriol) in kidney.

sympathetikey  C is the 3rd letter in the alphabet. Hence, D3 = Cholecalciferol +  
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. +2  


submitted by strugglebus(75),

As an edit: 108,001 people reported to have side effects when taking Hydrochlorothiazide. Among them, 25 people (0.02%) have Breast discharge

neonem  I think the best way to answer this question was by process of elimination. +  
sympathetikey  That's some bullshit lol +1  
karljeon  Haha I eliminated the answer by process of elimination. +6  
medschul  I eliminated thiazides by process of elimination :( +  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +1  


submitted by strugglebus(75),

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.

sympathetikey  Same! +  
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 :) +2  
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% +  


submitted by strugglebus(75),

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.

sympathetikey  Same! +  
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 :) +2  
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% +  


submitted by sympathetikey(363),

As stated below, the Left crus cerebri was damaged (see what it should normally look like below). This contains the corticospinal tract. Since the corticospinal tract decusates at the medulla, below the midbrain section we're looking at, you would see Contralateral (Right) Spastic Hemiparesis

sympathetikey  http://what-when-how.com/wp-content/uploads/2012/04/tmp15F11_thumb.jpg +5  
hello  What identifies that a cross-section is medulla vs midbrain vs pons? +1  
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. +5  
hello  @kernicterusthefrog Thank you. +  


submitted by hayayah(449),

NRTI's are associated with possible side effects of anemia, granulocytopenia, and myelosuppression.

sympathetikey  Especially zidovudine. +3  
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. +  


submitted by strugglebus(75),

The CI value contained 1, which means that its insignificant

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! +  


submitted by monoloco(64),

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.

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. +  


submitted by strugglebus(75),

I chose this solely because it was so damn specific

sympathetikey  Same. Learn something new every day: See more: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program +2  
karljeon  I didn't choose it because it was so damn specific. :( +9  


submitted by ergogenic22(55),

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

thepacksurvives  I think that there can also be a direct tear to the anal sphincter muscles +  
sympathetikey  A better answer choice would have been "damage to the nerves innervating the anal sphincter" but eh, ok. +4  


submitted by monoloco(64),

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.)

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? +3  


submitted by meningitis(178),

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)

sympathetikey  Brilliant. +2  
medschul  Would pheo have a normal resting BP though? +  
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. +5  
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. +  


submitted by mrmassador(7),

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

sympathetikey  Yes, but doesn't that mean maternal transmission? Men can have these diseases too, they just won't pass them on. +4  


submitted by hayayah(449),

A big thing here too is noticing that the ALP is decreased. Osteoblast activity is measured by bone ALP. I think that was the main focus here and not that you necessarily need to know the CBFA1 gene mutation.

sympathetikey  Exactly. That's the only way I got to the answer. +  
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 +  


submitted by monoloco(64),

Encapsulated organisms run rampant in patients who have no spleen, whether physically or functionally. (Recall the wide-array of sequalae sickle cell patients experience thanks to their functional autosplenectomy.)

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? +3  
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" :( +  
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. +