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Welcome to temmy’s page.
Contributor score: 126


Comments ...

 +2  (nbme23#43)
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rnioccgdA ot rD tr..aaSt amcnoaAiroencd si the msot oomcnm cseua fo guln crneac ni melfea non erssk.mo

drzed  Correction: he says it is the most common in NONSMOKERS and FEMALE SMOKERS. +7

 +0  (nbme23#42)
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haWt of fi teh enracc si a airotllueh acnecr ni het aeblddr deu ot ainritdoa ehtp.ray uwodl it ton sauce imairsl snigs

charcot_bouchard  Chance of bilateral ureteral ca is very rare. Also preincipal r/f for transitional cell ca is Smoking not radiation +
peridot  Hi temmy, yes it sounds like it would. There is a similar question from NBME 21 for those who have already taken that one (https://nbmeanswers.com/exam/nbme21/744). In that one, it's cancer in the uterus instead of bladder, but it's the same concept - the cancer can spread from the uterus into the bladder, or compress on the bladder, leading to bilateral hydroureter and hydronephrosis. So basically the takeaway point from that question and this question is that we learned a few things that can lead to bilateral hydronephrosis and hydroureter: 1. bladder cancer 2. uterine cancer 3. surgical and radiation treatment of cancer in that region, leading to bilateral fibrosis of the ureters. +2
peridot  Whoop just realized that urothelial carcinoma is a possible answer choice here. Well, I'm lost.... :x +
abcdefbhiximab  Urothelial carcinoma presents as painless hematuria with risk factors (i.e. smoking, aniline dyes) +1
mutteringly  In addition, the wording says "distal ureteral narrowing" which wouldn't happen with bladder cancer +

 +11  (nbme23#27)
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Dr aStrta lstka aubto eenscrai lacpailyr yaleeimptbir in eth aloltrpyacspi lneusev nda tsvianadiool ni het iaetrrosel as intasoc fo .atihisenm hTta saw htaw i tthhoug fo enhw i eresndaw het ns.euosqit


 +4  (nbme21#8)
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I raeeg ithw tahw has eenb adsi ubt soal eont atth eht inaettp lcdela ehr teirisntn to ehlp reh sedrsda hte lcnictfo bewteen teh owt ypnihcsias chiwh sah tognte erh irdoerw. aTht si hre eid.res ndA rofm waht i ahve de,etrahg reehw pbsieso,l hte tipastne wssieh osldhu be t.em

mambaforstep  true... i totally missed the part "pt CALLS HER PRIMARY CARE INTERNIST TO HELP ADDRESS THIS CONFLICT BTW THE 2 PHYSICIANS" smh +1

 +4  (nbme21#1)
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heylaHt peloep owh teg skci hiwt ovuirsvpra amy vhae a clncsibaliu lesnsli with tasaahrgil sa het lony ymmops.t uBt scekli llce tpatsine dna snitetpa twhi sdecesrae shspeeioaotim llwi vepeld[o bnoe woamrr alrfiue bcaseue het ruisv cffaet het ohceoiaepttim mtse sellc laideng ot acailstp iscres nda iiiylbnta orf hte bneo rwarmo to yaeleqadut psetencoam nhece eht owl eouerytcltci c. urvotrsauinvpo l.saue.aescpsdp eekcsh ni sd ki dhosypr ilatefs in usfet, taciplas riessc in leciks cell and asaghrlairt in hetro pesnitta.

henoch280  thanks. very helpful +

 -4  (nbme21#10)
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esaelp ehpl coraigncd ot tiewrns uoaqneti the patetni has a aolrmn ionan pga

ergogenic22  winter's formula is to look at the compensation to see if it is appropriate. PCO2 = 1.5[HCO3-] + 8 +/- 2 In this case, 1.5* 10 (Pt's bicarb) +8 +/-2 = 21 to 25 Pt's PO2 is 23, so compensation is appropriate. If PCO2 was below 21, it would be concomitant respiratory alkalosis +5
ergogenic22  in other words, winter's formula is not necessary for this question +2
the_sacramento_kings  lol unless you want to make sure its not A. +1
hello  @ergogenic22 Someone might use Winter's formula to rule out choice A. +
maxillarythirdmolar  respiratory depression of alcohol should rule out "A" +
baja_blast  Isn't the low pCO2 enough to rule out A? +1

 +3  (nbme21#27)
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ndA nerve ckpi na pnioto ahtt emska ouy nudso ailcirtc


 +5  (nbme21#27)
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wehn in uot,bd ickp na pnoe edned oi.tsuenq eyhT iegv eht eiaptnt an toynrtippuo to tsxlevemss pheseer htiw pgrptmnoi ormf eth doctor


 +5  (nbme21#40)
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Aslmot dlaeif hsit ntiequso ubt i pket egahrni Dr Strtaa namgrscie iprnnodagtals 2E EREEFEEVEEE


 +1  (nbme21#23)
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FIN mgmaa suemistlat arhsaoemgpc ot ecroupd snalrmouag


 +5  (nbme21#43)
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how i mreebmer it for all aueoogrmnsfraldm N.bIyF.. iindMgae atmnmaa by FNT aplah

aamGm rmsfo lphaa sintniaam sniua(sst ti). htTa si hyw nbafimiilx nda pttencaea(r FTN lphaa h)isirbniot lwil kbaer nowd the uoalagrnm fi eusd.


 +1  (nbme21#42)
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sbabie fo diiecatb mosm ned pu beign gebrig and ttah yam eadl to leruoshd iycaotsd

sahusema  If one of the answer choices was, "that baby gon be big lol" I would have gotten it right +18

 +0  (nbme21#48)
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i iknth het oentqiuss is tirnyg ot swho het emtpcriano of yunti nagmo yfimla bersemm nwhe hrtee is a tepiatn ohw is vdleo yb bhot iewf adn sik.d hTe ytdu fo teh cdotor is ot sneuer the imlyaf is edtniu in ptsorpu fo het iptntea eht adn in aecs ereht is tslli tolcnfci rggidarne atwh ot o,d uoy ues hte rhcheriya ewhre fwie smoce frist. i tge ti asw a dbum but shti wsa ym o igcl

 +3  (nbme21#16)
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pTye 2 ytpecomsneu podurec mset elscl and cratnfuats.

 +2  (nbme20#43)
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i ihktn ti si nto donarnge iivsinneytits ebcaues eht teseetroosnt slelev rae mn.roal eTyh uoldsh be ihgh ni IA.S





Subcomments ...

submitted by dr.xx(142),
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ghtir. he oullbyesat sumt mreani ni teh itanwgi eraa so that he si at danh ot atktca ihs wfei eernvhwe reh xeam esdn. og EBN!M

meningitis  I guess it was all about not offering battering information in order to not make matters worse since he will figure out that the wife told on him.. Also, its a HUGE STRETCH but the only reason I thought he should stay in the waiting room was just in case the wife died they could detain him and call the police for questioning. +10  
temmy  Also, he should stay there because his wife did not grant him the permission to see him. Patients requests trumps. +  
nephcard  Doctor should not believe what wife told her. There may be some other reason for injury so batttering information should not be provided. But her wish of not letting her husband in should be fulfilled +1  
charcot_bouchard  No. In real life patient lies. In Board ques they always tell the truth. Unless they make it very obvious. in fact its a board ques rule. So u believe her untill proven otherwise. +3  
drdoom  The prevailing rule of American medicine and law is individual autonomy. No other person is granted “default access” or privilege to another person’s body—that includes the physician! The physician must receive consent from a (conscious) “person” before they become “a patient”. In the same way, the person (the patient) must give consent before anyone else is permitted to be involved in her care, spouses included! +  


submitted by cbrodo(58),
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heT roeiptors usmlcno cuFci(usasl /senuccauulaicFutss rlgaiisc) ayrcr inaiofomrnt to the anbri aridngegr peiir,ooporpnct i,nvairtbo iidtiieacrsmnv otcuh nad spr.seeur hyislcaP aexm gdnsifni gtgesus a siolen here het( iamnhtolcsapi tcatr aierscr ipipn/rpnacki and pre,eeamturt nda tehes ewer lo)namr. enSci hte tiepant ash raobmnla fdinigns in hte orewl esirtmeet,xi dan mnlaro gdninisf in the reupp esiixetert,m het sarenw si ucasFcuils .iligasrc This si cubeeas airintfnoom rofm boyd sarae woble het lleve fo T6 is rrediac by caslriig adn oiomirtannf romf ydob aesar oebav eth velle of 6T si iedrrca yb uuanstec.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +3  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  


submitted by hipster_do(6),
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mI’ igngo ot asy i’st X lneikd aaolaeiglunimmmgab rehrat anht ,CSID tub eth ffrneeedci weenbte tehes wto rae iytn utb thsi si hwy I tnkih ’sit eth :mrfore

  • yBo deiarc(ens kris btu obth AB nad DCIS rea x kel)dni
  • eenrtrucR ibaartcel oitfnncsei but ndot’ etomnin arieradh ro sruhth whihc is in ICDS
  • meinelTi si reaft 6 mts,onh so het eh’rmost teinbsioda weor off.

DCSI lsduho eb etiydimleam ebeacsu heyt sujt tn’od ahve eht 2LI r.toecsrep CVID whoss up enwh yhetre’ 0204- ayser do.l You get tensba geimrnal cnteesr ni .obht No eomnnit fo naetsb iyhtcm sohwda hwihc si in DSCI.

placebo079  “Uniformly” low is also a clue; in CVID they are not. +4  
tea-cats-biscuits  This makes sense, though what really threw me off was that in Classic Bruton’s Agammaglobulinemia there’s near-zero B counts though (or at least that’s what FA and UTD says, “Absent B cells in peripheral blood” FA 116, 2018). The Q says the leukocyte count was normal though. Wouldn’t the leukocyte count include lymphocytes in the differential? And wouldn’t lymphocytes be low due to the near complete lack of B cells in peripheral circulation if it was BA? +1  
partybrockk  @tea-cats-biscuits Bruton’s is a failure of B cells to /MATURE/. So you get normal lymphocyte counts, decreased levels of immunoglobulins, and absent germinal centers. +5  
tea-cats-biscuits  @partybrockk That makes sense to me, but I keep getting hung up on how that’s not what either FA or UTD says about the classic lab findings of XLA. UTD specifically says this: “Laboratory findings include hypogammaglobulinemia/agammaglobulinemia, deficient antibody responses to immunizations, and absent or markedly reduced B cells in the blood,” and I previously quoted FA. I suppose it doesn’t really matter, but it’s definitely a bit frustrating unless I’m missing something about how absent B cells in the blood wouldn’t correlate to a decreased lymphocyte count ... +3  
temmy  please correct me if i am wrong cos i might be but my logic was there is decreases immunoglobulin uniformly meaning the B cells are uniformly absent and since they develop in the germinal center, the germinal center will be absent. +2  
almondbreeze  Picked 'decreased # of CD4 lymphocytes'.. ->Both CD4 and CD8 T lymphocytes were affected; the decrease was most pronounced for naïve T cells. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1809006/) +  


submitted by dubchak7(1),
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heTy setusgg Morostlosip ot nucrtetcao ID.S.A.sN yWh ont sIPP?

hayayah  PPI's don't have many side effects! If the question didn't involve the diarrhea side effect the answer would have been to give her a PPI. +1  
tsarcoidosis  I guess one takeaway is that PPIs don't directly cause diarrhea, but they do increase the risk for C-diff, which causes diarrhea. +12  
usmleuser007  PPI side-effects: + increased risk for C. diff + Increased risk for resp infections + can cause hypomagnesia + decrease absorption of (Ca2+, Mg2+, & iron) + increased risk of osteoporotic hip fractures (d/t low serum calcium) +1  
temmy  The patient got severe gastric burning and discomfort as an effect of the drug. My logic was since the patient was taking an NSAID it had to be a COX 1 inhibitor that destroys the protective barrier of the GI mucosa due to inhibition of prostaglandin so we needed to treat with a drug that will regenerate prostaglandin and prostaglandin is a vasodilation which might be the reason for the diarrhea. +  


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rdsnengoA esacu a.nce eostotnTeers is a etbrte snawre tanh rAtldodionnesa bc/ het estoeTertson si oicaesstda hiwt purb,tye rlnotondAsadei is oerm dstaaioces twih teh alnaedr a.ldgns

meningitis  I chose Testosterone but I almost chose GnRH because it is surged when starting puberty and therefore increases everything downstream. +10  
temmy  When answering the question, i thought to myself that if GnRH is correct, LH will be too cos GnRH stimulates the Leydig cells via LH to release testosterone. That left testosterone as the best answer because it had the most direct effect. +10  
goaiable  GnRH and LH are increased in a pulsatile fashion at the onset of puberty, so idk if that constitutes as the "rapid increase" that this question is asking for. Tripped me up also. +  
tallerthanmymom  I originally eliminated testosterone and chose androstanediol because women can have Acne Vulgaris too, and Testosterone should not be rising to the same degree. Do I not understand how puberty works? +1  
drzed  Women can still make testosterone though; and androstAnediOL is not the same as androstEnediONE +3  


submitted by drdre(21),
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gePa 065 AF 0219 beirdecss ecdsheh.aa

Ctrluse

  • reianlaUlt
  • 51 mins to 3 roush
  • boeailPtirr inap ithw ainlrtiomca adn oinhrhraer
  • :xT naiatSupmtr

neiMr iga

  • Utilealanr
  • 4 ot 27 usrho
  • iPtanglsu anip hiwt a,uesna ,abhppotohoi a,ohponpiobh amy ahev aar"u"
  • CN ,V mginsene or oobld sveels nraoiittri
  • x:T IS,NSDA ,natipstr rondteyordieahigm

eonnsTi

  • tlarlieaB
  • 4 ot 6 urosh
  • lkiBne-da napi
  • :xT alcagsin,se NSADI,S penhoceaniamt

drdre  yay formatting fail +  
drdoom  @drdre, next time try hitting enter twice ("start a new paragraph") before beginning a list. +  
temmy  cluster mostly seen in men +1  


submitted by neonem(550),
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This is a ceas fo taceu .outg oMnmsuiodo rutea saclsyrt are knaet up yb nihpluoster, dngaile to an tceau ntaaroflymim .ctranioe Tllc-se 'tnear aleylr evoidnlv ni utog erm(o htmduaiero ri.)tirtash

hungrybox  Great explanation! So frustrating that I got this wrong, should have been easy. +3  
temmy  the way i thought about it was how did the neutrophils get there? the answer is via increased vascular permeability +14  
nor16  they, unfortunately, did not ask " how did neutrophils get there" but " whats the cause of the swelling " not to confuse with " what causes the swelling " +1  
divya  absolutely right temmy. that's how i thought about it too. +  


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It asdi it wsa alfta to smale in e,rtuo adn the onqstuei adkes otbua eivl rnob gofrnfsip. iceSn teh smlae ’atnre gebin rbno in het fistr l,cape I iasd 05% elfsaem adn 0% .amsle

hungrybox  fuck i got baited +30  
jcrll  "live-born offspring" ← baited +21  
sympathetikey  Same :/ +  
arkmoses  smh +  
niboonsh  why is it 50% females tho? +2  
imgdoc  felt like an idiot after i figured out why i got this wrong. +1  
temmy  oh shit! +  
suckitnbme  This isn't exactly right as males can still be born as evidenced by individuals III 6,9,11. This basically an x-linked recessive disease. A carrier mother can still pass her normal X chromosome to a son (50% chance). It's just that the other 50% chance of passing an affected X chromosome results in death of the fetus in utero. Thus all males actually born will not be affected. +2  
makinallkindzofgainz  @suckitnbme, Correct, but if you're a live-born male, you 100% for sure do NOT have the disease, so the chance of a live-born male "being affected" is 0. +3  
spow  @suckitnbme it's not X-linked recessive, otherwise every single son would be affected and therefore have died in utero. It's X-linked dominant +2  
qball  Jail-baited +  


submitted by sympathetikey(1252),
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eTh ewhol "ckspi at het so.ei.su.lnesca oems degeiln"b, amde me hknti osPiasrsi. ulohSd ahev geno whti iciAntc sesraiKto sbdea no eht neatpti oiystrh so(lt fo sun ru)oexep.s

ticiAcn toisKersa

inragaPlenmt snisoel edcsau by uns orpe.uxse lmaS,l or,uhg ehsmattyeoru ro onbshrwi upaespl psrla.oqu e iRsk fo smousuqa lelc arnoccmai si ontrporailpo to redeeg fo ilpielheat sa.iydpals

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


submitted by neonem(550),
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aroMj ikrs rotafc orf rocita tniiesdosc si ,pseneioytrhn dan ni stih sace htigm eb due to ecnaoci ues, whihc ausces erkmda rnhypnot.isee ssstcnoiDie asceu a trea ni hte actuin nmtaii -- blodo nca oflw cwsradkab tnoi teh rmeiciuadrp dan caues otndamaep. hTis mafsentsi as selarkcc in teh nglu edu ot ropo tfle uvtlaienrcr ctoinufn osifl/i(gnailtdlci rmolepb deu ot pmoso.scen)ir

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9  
temmy  please why is there where a diastolic mumur? +1  
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8  
garibay92  Does anyone know why is this patient's tepmerature elevated? +1  
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1  
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +  
almondbreeze  he's only 28 - another clue for marfan? +  
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2  
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1  
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +1  


submitted by aishu007(3),
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cna eonany xelanpi hwy aiesoroeccccfetnlasu is eth srenaw e?ehr

priapism  Best I can guess is that both S. aureus and E. faecalis can cause UTI, but S. aureus is described as having clusters where as the other Gm+ cocci are in chains +6  
nala_ula  My doubt here in this question is the fact that Enterococcus faecalis is a normal gut microorganism that causes these different symptoms of sickness after genitoruinary or gastrointestinal procedures... but in this question there is no mention of any procedures. +  
fez_karim  its says chains, so not staph. only other is entero +  
temmy  according to first aid, staph aureus is not one of the high yield bugs for UTIs +1  
temmy  uti bugs are E.Coli Staph saprophyticus Klebsiella pneumonia Serratia Marcescens Enterococcus Proteus mirabilis Pseudomonad aeruginosa +  
privatejoker  Where in FA 2019 does it list that C.coccus is specifically in chains? +  
privatejoker  E.Coccus* i mean +  
divya  @privatejoker FA 2018 Pg 134 table +  
jennybones  @privatejoker Enterococcus is Group-D STREP. Streps are arranged in chains. +1  
santal  FA 2019 Page 639, too. +  
backwardsprogress  Enteroccocus is also a pretty common cause of chronic prostatitis, which was the give away in the prompt if you didnt know the characteristics of entero: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715713/ +  


submitted by aishu007(3),
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acn nonaye eplxain ywh olcisaorafnceccesute si het wrnesa ee?rh

priapism  Best I can guess is that both S. aureus and E. faecalis can cause UTI, but S. aureus is described as having clusters where as the other Gm+ cocci are in chains +6  
nala_ula  My doubt here in this question is the fact that Enterococcus faecalis is a normal gut microorganism that causes these different symptoms of sickness after genitoruinary or gastrointestinal procedures... but in this question there is no mention of any procedures. +  
fez_karim  its says chains, so not staph. only other is entero +  
temmy  according to first aid, staph aureus is not one of the high yield bugs for UTIs +1  
temmy  uti bugs are E.Coli Staph saprophyticus Klebsiella pneumonia Serratia Marcescens Enterococcus Proteus mirabilis Pseudomonad aeruginosa +  
privatejoker  Where in FA 2019 does it list that C.coccus is specifically in chains? +  
privatejoker  E.Coccus* i mean +  
divya  @privatejoker FA 2018 Pg 134 table +  
jennybones  @privatejoker Enterococcus is Group-D STREP. Streps are arranged in chains. +1  
santal  FA 2019 Page 639, too. +  
backwardsprogress  Enteroccocus is also a pretty common cause of chronic prostatitis, which was the give away in the prompt if you didnt know the characteristics of entero: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715713/ +  


submitted by mcl(579),
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Not reus fi shit si hte trhig ayw to nkhti taoub it, utb fi PT nad PTT rea tbho ,olgrdpoen tish sotm ilkely ensma ereth is a blmpoer with teh moomnc pawtayh ak(a ocartf X).

temmy  exactly...i just thought the problem has to be where they meet or somewhere similar to both..hence the common pathway 12(PTT Heparin) 7 (PT, Warfarin) 11 9 10 5 2 1 In my head, both sides are looking for the perfect 10 +  


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nI eth atgre wsdor of Dr trtaS:a

nngadslPr"ioat 2E etmidsae eveeeeee"efreee

SNsAID g-;-t& klboc itdnsarnplago syn

thisisfine   This is all I heard in my head +7  
temmy  Me it was so weird +  
peridot  I do want to add, that while PGE2 is the right answer, FA19 p.213 says that IL-1 and TNF are involved as well. However, because the question asks about what is going on in the hypothalamus, the answer is PGE2. If the question had been asking about what the macrophages were releasing to influence the hypothalamus, then the answer would have been IL-1 or TNF (FA didn't specify if it was TNF-a though...). +1  
feeeeeever  You know why I'm here +5  


submitted by yotsubato(968),
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Wyh is ihs biidoL aonr?lm Its' loatlty xdpeecte tath he may hvae edecdur bioldi raetf sih iewf eidd 2 reysa goa romf moes lebriohr ogldopenr es.lilns

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by yotsubato(968),
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Why is ish iibdoL mn?rloa st'I ttlaoyl cdexepet taht eh aym hvea crdduee dbilio retaf ihs ewif dide 2 asery aog rfom esom elbrohir lrgdpoone linl.ess

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by didelphus(54),
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ynA aedi ywh yphechoearlmir ts'in an ans?erw Teh raahired ldouw cause na rlonam anion pga y(mcorelrhc)iehp emtliaocb aocsi.sdi

charcot_bouchard  this is the problem bet uw and nbme. in uw it would be for sure a gotcha ques. but in nbme they are usually looking for most obvious. also look what they are asking "most likely". baby would dev low Na before acidosis. Thats my 2 cents +21  
temmy  hyperchloremia will not account for the seizure that brought the patient to the hospital. seizures according to first aid is caused by hypocalcemia and hyponatremia +1  
cry2mucheveryday  Children with diarrhoea who drink large amounts of water or other hypotonic fluids containing very low concentrations of salt and other solutes, or who receive intravenous infusions of 50% glucose in water, may develop hyponatraemia. This occurs because water is absorbed from the gut while the loss of salt (NaCl) continues, causing net losses of sodium in excess of water. The principal features of hyponatraemic dehydration are: there is a deficit of water and sodium, but the deficit of sodium is greater; serum sodium concentration is low (<130 mmol/l); serum osmolality is low (<275 mOsmol/l); the child is lethargic; infrequently, there are seizures. https://rehydrate.org/diarrhoea/tmsdd/2med.htm#CONSEQUENCES%20OF%20WATERY%20DIARRHOEA +  
cry2mucheveryday  Also, why is this being given formula...? May be lactase deficiency...which leads to osmotic diarrhea...leads to hyponatremia(goljan) Aren't newborns supposed to be kept on exclusive breast milk till 6 months?? +  
hello  @cry2mucheveryday Don't read too much into it. The fact that the baby is receiving formula isn't relevant to answering the Q. Btw, not everyone breast feeds. Additionally, the Q wouldn't make much sense if it said "they ran out of breastmilk"... +1  
hello  @cry2mucheveryday Being on formula then the parents running out of formula is more of a clue for water intoxication. This is typically the scenario that water intoxication presents. However, I suppose if for some reason the baby was being breastfed and the parents switched to exclusively waterfeeding (and no other foods), then water intoxication would also result. +  


submitted by haliburton(208),
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sThi si atewr nt.ociitnoaxi wm97nbptevw/.h5/m..nlh/17pb:gwsi8nod7tui/c.

thisisfine   Agreed! It's along the lines of those marathon runners who collapse questions. Nothing but water for 24 hours = getting rid of too much sodium. +1  
temmy  are we just going to ignore the diarrhea for 3 days? what is its significance +4  
kard  Temmy, We aint Ignoring the Diarrhea, Actually the most likely electrolytes to get lost with it is sodium> chloride> potassium> bicarbonate... Plus the Water intoxication -> HYPONATREMIA +1  
bronchophony  why not hypoglycemia? +1  
saulgoodman  Because glucose is not an electrolyte, it does not conduct electricity in solution. The question is asking "Which of the following electrolyte abnormalities". +2  


submitted by usmleuser007(370),
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jsut a c.un.h.h. romlaeezOp si saywal the rhtgi wsearn

nala_ula  Famotidine is an H2 blocker which really only stops acid secretion via the stimulation of H+/K+ ATPase by histamine, but it still has vagus and gastrin stimulation. If you use Omeprazole, you get irreversible inhibition of the pump itself which stops the secretion of acid even if there is histamine, gastrin, vagus stimulation. +6  
temmy  what about the healing of her mucosa. Is that not the action of prostaglandin?. That threw me off cos according to FA, misoprostol increases secretion of the gastric mucosa +5  
cry2mucheveryday  same doubt..marked miso +2  
sahusema  I guess because misoprostol is more associated with treatment of NSAID related ulcers and PPIs are 1st line DOC for GERD? +1  
makinallkindzofgainz  @temmy, I think that Omeprazole is a better answer because although Misoprostol would promote healing of her esophageal mucosa, it wouldn't do anything to relieve the symptoms of GERD (due to acidic contents in the esophagus) +  


submitted by yo(78),
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hsiT dcorreuc ihwtin 6 urosh nad saucde eoms ulyarmpno eeamd dna rertyoprsia tdsesrsi taefr a annruissotf edausc by teh ndso'ro teynkelcauoit- betsioadni just tedgrsoiny teh npcsrteeii hprusiloten nda syriapeorrt nalodelheti le.lsc

lwhei lpeisanayriahg/caxll nac aesuc iryrpasrteo aerstr nda shock it has a etahosmw irneedfft tp,ecriu on z,gehwein hnicitess ro trweaevh dan angiccord ot strfi Adi ti hnappes hinwit stnuiem to 23- rsouh iwchh is ta alets ldbueo whta e'rwe ignees re.he alos reaewb fo IAg ifcnidete peolpe ni shti chocei.

,PE eh I t'ndo ktinh it setcffa aoP2 ahtt ofetn humc ragoiccnd ot isth upesr pedur hihg ldeiy seorure.c utb huh yhea sdte'no elef EP aidkn qeo usitnewumst3#.i:./amp01/c0rcecplek/esopdm1terio-e0di/cah9nt2c

i,nemapon rhtig aetfr lla eth niufiosn nssiebsu adn no emotnin of evrfe or tan?iyhng a.hN

og ot peag 114 fo ifsrt ia.d mI' pytret srue ew deen ot wokn ruo inntpnnos/iutlafars acrp uesaecb ti ujst eekps cogmni up in uodrwl tbu stih eholw exma is a tpaocs.hro

ovigFre em fi I dema a katgrsneiwmo/ otbau thgni,nya I otslym tgo noif morf fisrt iad. lpz creorct if rtehe si a m,eaksit ogod cukl.

hungrybox  we gonna make it bro +7  
hungrybox  or sis +8  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +6  
athenathefirst  I hope you guys made it. Your post 9 months ago +1  


submitted by hungrybox(968),
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tnnugtHniso' eesiasd

  • apcinitinota: esh has a rsiilma rsoedrid sa erh terahf tub ddei reralei

eRmbmere THN"U 4 na mlinaa, tup ti in a "CGe.A uitnnHnitg ngee dofun on orhomeCsom 4. ACG si teh idtueeilrcnto are:etp

  • Caer,oh daceatu selucun
  • txiAaa
  • ymlGoo sonred(ip)se
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +15  
sbryant6  Side note: atrophy of the caudate nucleus leads to a widened anterior horn of the lateral ventricle. I've seen it worded both ways in UWorld. +  
foulari112  How would you differentiate this from Frontotemporal lobe dementia +  
temmy  Foulari 112..the ageof the patient and the anticipation cos her dad had it too. Also in frontotemporal pick, you will see personality changes where they act completely different vs huntington where they are aggressive and depressed. +1  
castlblack  CAG = Caudate loses ACh and GABA (from FA) also points you to caudate +  


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VA stuFisal our-tre lbodo form hte aarleirt etsyms to het veunos ysemts, gnsasi-ybp hte reorseAlit = esrcneaI LP t-;g--& ENREAICS V.R lAl in lal = eIcranes C.O

gondccriA ot oUrW,ld het ilrerateos aer a mrajo cseruo fo eteaisscrn ... so ysgpabnsi eht tlsoeraeir lrtsseu in a seerdeca ni oTlta prelaPierh stasiRcnee ... agciuns an einesrca ni the erta nda vluoem of olbod tnerrguni to the .areht I ma tyrept uers reeth is omer to eth hpysiogoly nbhedi ,tsih tbu I hoep siht edlpineax a llt.tei

big92  "Immediately following creation, arteriovenous fistula (AVF) is associated with an increase in cardiac output (CO), achieved predominantly through a reduction in systemic vascular resistance, increased myocardial contractility, and an increase in stroke volume (SV) and heart rate. Over the following week, circulating blood volume increases in conjunction with increases in atrial and brain natriuretic peptides. These alterations are associated with early increases in left ventricular (LV) filling pressure with the potential for resultant impact on atrial and ventricular chamber dimensions and function." (PMID: 25258554) There's also another study by Epstein from the 1950s looking at the effects of AVF's effect on CO in men (PMID: 13052718). Apparently, the increase in resting CO is a big problem because it can lead to high-output cardiac failure (LVH). +23  
hungrybox  Jesus big92 you went in on the research lmao u must be MSTP +6  
temmy  big92 you are right. that is why pagets disease pagets have high output cardiac failure because of the av shunts. +4  
kevin  what is "increase PL" +2  


submitted by hungrybox(968),
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eoms wnorg eass:rnw

a*ksme esens c/b taesoslyblm rea rsoupesrrc ot tycoleurgsna, whcih ues MPO ot gifht fof iiotefsncn

temmy  Hungrybox aka life saver +1  
hello  Thank you!!! +  
bbr  ....uh yeah im pretty sure we just call em "Auer Rods" now. Appreciate the answer tho! +6  


submitted by hungrybox(968),
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ehrot ranwss:e

hionnitibi fo H2 teespo:rrc (fro )EGRD reepvnt tcasgir cdia oietecrsn (,icmetiedin

itibhinion of raoodestshpihsespe :E()PD

  • phlothieleyn s(aa)tmh btihisni PcMA PED
  • fas-nil i(ckd ilps)l orf DE itibnhi PcMG EPD

β2 osts:gina ro(f hmata)s esuca codbnrotoiilnha

  • erblltauo ostr(h tigcna - A fro tueA)c
  • teealm,osrl mlrrofeoto gln(o gaitnc - plxoayhpir)s

di(k pyotmhcyel nmmbreea saitzi)nbiatol

hungrybox  H2 blockers are the -tidines +2  
yotsubato  > dickpills lol +16  
temmy  hungrybox, you are a life saver +1  
cienfuegos  Via FA: take H2 before you dine, think "table for 2" to remember H2 +2  


submitted by moo(-1),
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if eth sulng eerw lerac ot tltaoscauniu dan eht idk even dasi he od'estn watn to be on eth tmae namroye ywh 'ctunlod it eb igimnlear?ng

amarousis  malingering would be a conscious faking of symptoms to avoid being on the team. he wouldn't have the mid-systolic click and he would probably complain of his symptoms all the time and not just limited to during exertion. +1  
temmy  malingering is also doing it for some external gain. which was not indicated in the stem +1  
garibay92  Also, patients with asthma are usually asymptomatic at the time of physical exam unless they are examined precisely during the attack. +  


submitted by cantaloupe5(72),
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scPcroes fo mnniioetial rfo hist oe.n Tow you can ltnmieaei tmalyemdiie just ofrm oknogli ta het mccaolieibh awpyhta thrac. Teh rteoh otw deierrqu gwknleeod taht nmalieneu is orme eotpteirvc anth mlnihepnoae tshi( si ywh srdeehad nrbu ermo islaye). aBseeuc eeplmhinoan is essl ce,retvoipt rehte ouwld be omer not sles OSR mfor ghtsu.iln

temmy  i don't understand this at all. i am completely blank...please help +3  
henoch280  @temmy. This question tests our knowledge on albinism which is normally a tyrosinase deficiency disease but the vignette states that the boy's albinism is caused by a genetic mutation in the TYRP1 gene which is shown in the biochemical pathway. A gene that helps in the synthesis of Eumelanin. Now you have to understand that all precursors before that gene is the pathway would still be available if not increased which make 2 of the options in the question wrong. you also have to understand this: (Eu)melanin = (normo)melanin i.e normal melanin which is protective to the skin, decreases reactive oxygen species and gives the dark pigments to the iris, choroid, skin, hair e.t.c. while (feo)melanin = (fake)melanin i.e pheomelanin, the one present in our patient here which is less protective again the uv rays, cannot pigment and cannot decrease ROS generated in the skin. i hope this helps +26  
eacv  @henoch280 thank u very much! I got it right by luck but now i do understand :D +  


submitted by neonem(550),
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oeihnMpr is a mu odpiio intsago - neo dsaevre feftec fo siodipo si stam clel argalntnuoeid hatt si IEnn-denidpetge. leReeas of mshenaiit si kain ot an hyacpcatilan oantriec g-&t;- pt,sriuir ec.t

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


submitted by moneysacs(1),
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Wyh is odes a PAD eartf thrib ersutl ni "higrhe ahnt orlanm flte uctaevrrnil aiaccrd otpu"tu vore eeracnids hrgti" uiltervracn ?OP"2 Dseo eth lmpu yretra ;-tg-& troaa hntsu cmeboe severerd eartf t,ihrb so highre gyeonx ratao dobol ouwld fwlo ckba inot teh grhti eelntcrv?i I gte thta reom obold oluwd be dmppue to eht etfl ,rlceinvet uilerngst in VHL/HV,R ubt tn'do ndnestdrua teh O2 tib.

usmleuser007  1) higher than normal CO b/c blood is shunted from aorta to pulmonary arteries. This blood is added to the volume that was pumped into the pulmonary arteries by the RV. Now when the oxygenated blood returns to the LA & LV, the O2 content would be greater d/t higher blood volume. Also for that same reason more blood is returning to the LV (d/t LV volume plus fraction of RV volume). This increased the CO. Right--> Left shunts have late cyanosis b/c the RV is pushing against the excess pressure generated by the LV. This leads to Eisenmenger Syndrome as RV enlarges and pushes against the pressure from the LV in the PDA. Thus shifting Left to right to right to Left and thus the late cyanosis +2  
temmy  The anatomy is aorta-pulmonary artery-pulmonary veins-left atrium-left ventricle Notice that the blood did not come across the right heart at all and because of the LEFT TO RIGHT shunt of the PDA, we add more volume to the LEFT side. Hence the increased left ventricular output +2  


submitted by ihavenolife(66),
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dIk fi it hslpe tbu I gto ti using hte oHt noe-TB AsEKt cemnomni

Hot g&;-t IL 1 )e(eFvr

T elcl ntiomlsuiat -t;g& IL 2

onBe ormarw otanmlisiut g&t;- IL 3

gIE -tg&; LI 4

IgA -> IL 5

aKeut hpsea eopnrit g&;-t IL 6

temmy  cyclosporine inhibits transcription of IL2 +14  
mysticsoul  FA2018 Pg 120 +2  
teepot123  same page also for 2019 edition^ +  


submitted by hayayah(1056),
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owDn nydormeS b:Lsa

  • ci.n cnhlua aetnynsrlccu
  • nci. GCh
  • c.in ibnhiin
  • ereacsedd FPA
  • cdseereda AAPPP
celeste  I remember this as Down Syndrome has high HI (hCg and inhibit) +16  
temmy  Thanks celeste. I'll remember Hi +1  


submitted by asdfghjkl(2),
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Aenyno kown hwy IF-G1 wtl'onud eb aneercisd sa ell?w RGHH si ailttumdes ni goccyhpylemi tsts.ae

nala_ula  Honestly, it's something that has confused me for a while. Why is it that GH secretion is stimulated by hypoglycemia? I mean, it's literally called growth hormone (for growth!), and hypoglycemia, which is basically a "starvation" state, will stimulate this hormone? +  
shaeking  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529368/ This might help answer your question. I basically didn't pick IGF-1 because it would increase the uptake of glucose leading to a worsen hypoglycemic state. Didn't have a true reason otherwise. +  
temmy  IGF-1 is regulated by insulin. so it will be decreased because insulin levels are also low. +2  
nala_ula  thank you @shaeking! +  
nwinkelmann  I found this and it also explains to a more genetic/cellular level. Essentially, it says that starvation induces some factors that cause GH resistance and IGF1 suppression. +1  
nwinkelmann  Sorry forgot the link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575072/ +