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Welcome to thomasalterman’s page.
Contributor score: 147


Comments ...

 +1  (step2ck_form7#23)

Post-viral tender goiter with thyroiditis = subacute granulomatous thyroiditis.


 +0  (step2ck_form7#43)

The PTX is sufficiently small to be managed with observation. The criteria vary. FA says ≤ 2 cm, which doesn't help for this question.

The following article has advice regarding an asymptomatic apical PTX but the advice don't apply to this patient who is symptomatic.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203987/


 +1  (step2ck_form7#2)

this question would be a lot easier if the answer choice was worded "spinal epidural hematoma"

seagull  Yes! I chose dural lacerations. I quickly wrote off epidural hematoma since we usually think of it as head trauma. However, as history has shown. These authors are ass. +

 +2  (step2ck_form7#45)

priority for AD patients is rate control. After controlling rate you can throw on something extra for pressure control but rate control comes first.


 +1  (step2ck_form7#21)

My reasoning: We know she has preeclampsia, so what other information might be helpful? - platelets could evaluate for HELLP and AFLP - everything else has no indication. US pelvis is a weaker choice given patient has no documented signs of abruption (pelvic pain, vaginal bleeding, FHR abnormalities)


 +0  (step2ck_form7#17)

my reasoning:

  • diuretics cause hypokalemia →
  • hypokalemia causes ↑ digoxin binding to Na/K ATPase → cardiac dysfunction (i.e. PVCs)
seagull  They don't specify the exact diuretic. More cause hyperkalemia than not. Also, digoxin causes hyperkalemia (mild). This questions answer is infact opposite to what is a logical conclusion. +2

 +3  (nbme21#11)
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yM ttoghhu corseps wsa tath puprsta-otm bidegnel is laulysu elaedrt to eht u,erstu and umhc of eth vpeicl ivasrce is pspieldu by ahbecrns of eth elnratin calii rtey.ar

neonem  This sounds like a case of acute endometritis. In any case, uterus is supplied by uterine artery (branch of internal iliac artery) with collateral flow from ovarian artery (comes right off aorta). I don't think there are any branches of external iliac artery into the pelvis; it becomes femoral artery once it passes under inguinal ligament. +4
tsl19  Here's a picture that I found helpful [Female Reproductive Tract arterial supply] (https://teachmeanatomy.info/wp-content/uploads/Blood-Supply-to-Female-Reproductive-Tract.jpg) +14
sympathetikey  @tsl - Thank you! +
step1soon  uworld Qid:11908 +

 +8  (nbme23#46)
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kSin psovredi noalnistui adn etenpsvr athe s.osl hTis tp'esinat obyd lwil mcesetapon rof idacneres raet fo ahte sslo yb enncisirga etomcilab .tera

davidw  This is directly from Goljan I) Hypovolemic shock may occur due to loss of plasma from the burn surface (refer to Chapter 5). • Loss of protein from the plasma loss may result in generalized pitting edema. II) Infection of the wound site and sepsis may occur. (a) Sepsis due to Pseudomonas aeruginosa is the most common cause of infection in burn patients. (b) Other pathogens include methicillin-resistant S. aureus and Candida species. (3) Curling ulcers may occur in the proximal duodenum (refer to Chapter 18). (4) Hypermetabolic syndrome may occur if >40% of the body surface is burned. +12
yex  Can someone explain why is it not increased ECF? +19
charcot_bouchard  i picked same. Increased ECF but cant remember why. Can you explain WHY it is increased ECF? what was ur reasoning +2
isotopes  Burns would lead to a decrease in ECF because the protection from fluid loss is absent; it can lead to shock. :) +1
tinydoc  My reasoning behind picking ↑ ECV was that your losing fluid but not electrolytes with the burn ⇒ the ecv would have increased osmolarity, so the fluid from the ICV would be pushed the the ECV. It made sense to me at the time. I guess technically its wrong because the loss of fluids and the gain of fluids would amount to pretty much the same thing. But the insulation and heat loss thing makes sense I guess. +
yex  Increased ECF, bc I was thinking about the edema formation.... :-/ +3
atbangura  I picked increased ECF because burns increase the capillary permeability coefficient, but now that I am going over it I realized that increasing the permeability would only transfer plasma volume to the interstitial volume, which are both a part of the ECF so therefore ECF would not change. SMH +5
aisel1787  thanks +
69_nbme_420  Burns (and Diarrhea) cause ISOsmotic volume contraction; Costanzo BRS Physio +
tiagob  in severe burned patient, also has increased fluid in third spacing or interstitial (leading EDEMA). Different extracellular space is interstitial and vascular +
peridot  I also wanted to add, another huge job of the skin is to prevent loss of fluid. Burn patients are easily dehydrated because they've lost that barrier. This helped me lean away from increased ECV - despite the edema (from one compartment to another) as others have mentioned above, there is a loss in overall ECV due to evaporation from body. +

 +6  (nbme23#24)
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heT tanepit sha TNA oarndycse to alner iae.hcsim eDu to uurltab ero,cisns the ietapnt illw aehv na etvdleae Ne.Fa ehT p'itnaest uiern wlli osal eb idet,ul btu shit lwli be teferdelc by the lwo reuni yoltmlo,sia tno eth FNea

mousie  Hypotension can also cause pre renal azotemia with a FENa <1%.... How do you know this is ischemic ATN and not hypotension induced Prerenal Azotemia? +11
sympathetikey  I had the same thought as you @mousie, but I think "azotemia" and low urine output push it more towards ATN (looking back; I got it wrong too). Plus, the initially MVC / muscle damage probably caused some tubule injury by itself. +2
ajo  This might help clarify why the pt. has ATN rather than pre renal azotemia. The question did mention, though subtly, that the bleeding was controlled. That most likely indicates that his hypovolemia has been corrected. Developing azotemia 24 hrs after correction of hypovolemia is more suggestive of ATN (since he doesn't have hypovolemia anymore). I hope that helps and feel free to correct me, if I am wrong. +39
ajo  In addition to my earlier comment, I just noticed the question also explicitly mentioned that he was fully volume restored. Which is consistent with my earlier assumption! +14
gh889  Although initially, hypotension causes prerenal azotemia, the volume correction pushes you away from prerenal azotemia. but they want you to remember that in hypovolemia, the kidneys are also becoming ischemic, and so development of azotemia 24 hours later is more indicative of intrarenal azotemia due to ATN +
sugaplum  for anyone who wants to see it: FA 2019 pg591 +1
divya  i'm confused about one thing. if the tubules aren't working like they should, the bun:cr ratio falls right? doesn't that essentially mean azotemia reduces too? +
osler_weber_rendu  Lets all take a moment to admire how shit this question is "Bp 90/60.""Repeated episodes of hypotension in the OR" and still the answer is ATN +4
donttrustmyanswers  @osler_wever_rendu ATN can be caused by ischemia. +2

 +25  (nbme23#4)
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lairMaa acn marpii teihpac solsoeeenugincg nad nac asol emsunco cosugel for sit wno leotmicab dsnmea.d

yotsubato  Truly a bull shit question... Its not in FA, Sketchy or Pathoma +54
meningitis  I will try to remember this by associating it with P. vivax, that stay in the liver (liver=gluconeogenesis). Thank you @thomasalterman. +8
focus  ADDITIONAL INFO: If we were asked to identify the stage of the lifecycle, it would be (intra-erythrocytic) schizont stage: https://labmedicineblog.files.wordpress.com/2018/06/mal3.jpg?w=840 Life-cycle: https://www.cddep.org/wp-content/uploads/2017/06/malaria-life-cycle_4-1440x1080.jpg +1
dul071  i solved this question by seeing that there are hemolytic inclusions resembling parasites and that they require glucose being a living organism, hence hypoglycemia. +
curlycheesefriesguy  I knew that malaria causes hypoglycemia but i saw the word drowsy and like an idiot thought it was african sleeping sickness +

 +4  (nbme23#30)
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eCptommlen si opanritmt rof rnimgoev nemmui ep,mslcoxe os attsnepi hiwt pnmomtlcee iineseeifccd (*cc)-41 era mroe lekyli to eldpoev .LES 1qC si a bteter sarwen hnta hant MBL )(D cb/ eth MLB yaptwha si retirdgeg by carabi.te

myoclonictonicbionic  Thats the reason I put MBL, because the question mentioned that it got worse when she went to the beach so I was thinking some sort of contact with bacteria may have exacerbated her immune system. +
thotcandy  @myoclonictonicbionic i think that's just the typical SLE photosensitive malar/butterfly rash +1
dna_at  FYI it is less to do with immune complex clearance than it is to do with clearance of apoptotic debris. The overload of apoptotic autoantigens contributes to loss of tolerance -> SLE. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4764694/#S4title +1

 +9  (nbme23#16)
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Meleyhats ysthmeealt ADN, anmgik eht ADN aretsitsn to tosentriicr sanoelnudesce

*hvszrjo:dctlty7RKmLdtvoUonmtuz_P4arltnsw3p.ThGi4megG2iffp.Liudrn/xYrteeZ/vefcjTs.t/t


 +21  (nbme23#21)
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eSh ustj mcteopdel eht ecruos fo it,xmibaru chhwi sargtte C20D ep.rocetrs -Bellc ynefcdceii anc prsedsopei ot bclteraai itsnoifcen.

b) MB leaufir is otn acdtaiesso tiwh imirb)txc au )grodnw go)nerw sith ocrucs inw/ -107 adsy of giatsnrt tn,ertamet dna dwluo ton courc etraf olctngpemi a tm4no-h uerosc of tiri.uxabm

meningitis  Forgot the time frame for Serum sickness and got it wrong.. thanks @thomasalterman +20
stinkysulfaeggs  Same. Crap. +2
medstudent22  Taking it one step further - B-cell depletion = decreased Ab secretion = decreased opsonization. Opsonization with subsequent phagocytosis by spleen = #1 mechanism by which encapsulated bacteria (ie Strep Pneumo) are degraded. +1

 +5  (nbme23#23)
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lnTdxieipehhyr nad npeniBtezor aer aiasursiinnctcm atht acn taert het rnesitg roertm dna tiidgiry of nssii.apromnk

mousie  haloperidol induced Parkinson's... ? adding a anticholinergic can counter these adverse effects of the antipsychotic .. ? +3
fulminant_life  @mousie yeah it balances the dopamine-cholinergic imbalance caused by the antipsychotics +
kai  +So antipsychotics induce Extrapyramidal side effects which is drug induced Parkinson = low Dopamine High Ach, and you would treat this with anticholinergic (Benztropine).This is neurologic. +Antipsychotics also produce non-neurologic, systemic anti-cholinergic effects like dry mouth, sedation, hypotension etc +

 +11  (nbme23#17)
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eTh tsmo mirntpato tsinh to het iqotusen ear sa solw,olf htiw #2 gbien hte toms :spcieifc

)1 patietn torresp pina hwti edavrheo nomito dna seotprr trrcuenre erehdaov iontmo rginud okrw. Odvreahe noomti nca eagdma eth arsutsnipaspu scmule ude to nitgniememp by the oarcnmo.i

2) nPai si srwot thwi nieranlt ratitono of teh lrudesho - sith is snoectsnit htiw eth dsgfnini of eth atmecnpy- ,test hcwih cniiaedst a siansarupstup un.yjri

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

 +13  (nbme23#29)
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ePttnia is trnuerc aeefts-dbr, so we cna mtienleia uectorsf rfc(uesto is odnuf ni nehyo dan tfursi nad emso lfmaruo, tbu not ni rbetas )klmi. etPntia sha degurcin scenuabsst tbu no eslcogu ni hte erinu, os eh umst emos ocglueosnn- sgra.u My lefitrndfiae rof ciedugnr -snoclegoun asgsur in eth uerni is sirsddreo ufscerto lamtseoibm or aaelgtosc m.ilmetaosb eW hvae iiemltdaen cu,oetrfs os ttha saleve su itwh alnkaaitosegc eenfcyidic ro saciscl cmtasoe.igaal

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

 +3  (nbme23#44)
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Pnieatt sha a rtuacefr ot het frrieino .irotb iTsh anc gdm V2 or ertpan het RI se.cuml nlyO IR prmettnena woudl pimari .osvini

nlkrueger  if this isn't a globe rupture than idk what is tbh +15
mousie  the air in the center of the globe made me think rupture too ..... +3
sajaqua1  There may be some global rupture, but impairment of one of the ocular muscles causing diplopia would still be the best explanation for this patient's double vision. +12
catch-22  Globe rupture leads to entrapment of the IR muscle which causes diplopia. The question is asking what is causing his visual complaints, which is diplopia, not loss of vision. +2

 +12  (nbme23#32)
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tainetP hsa a nigoagln tyc,s whhci nca npsaeooulsnyt s.ersegr

medschul  Mine would beg to differ >:O +26
usmleuser007  Where would I have come across something like this (FA, Pathoma, or out of my S)? +5
motherfucker2  I thought this bitch was a lipoma. Mother fucker +9
divya  mf2 lipomas is fat. although fat may exist in liquid form, its still opaque, therefore negative transillumination. unlike ganglion cyst. +4
beanie368  Only knew this because I have one that comes and goes... +3
cbreland  I thought these were like a 1-way valve? Didn't think it would regress if that was a case? +

 +8  (nbme23#31)
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A ntoamlrobs is an amutreim BCR, so 'tis eedtavle ni satset fo neadsecri .ptossoeameihi

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +57
someduck3  The term "Normoblast" isn't even in first aid. +35
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +18
tinydoc  I wish they would stop making it so every other question I know the answer and I can't find it among the answer choices because they decided to use some medical thesaurus on us. +17
qball  Metamyelocytes = Precursor to neutrophils Siderophages = hemosiderin-containing macrophage aka heart failure cells +8
llamastep1  Theres a UWorld question about Parvovirus B19 that mentions "giant pronormoblasts" that helped me make the connection +5
fexx  I got it right but would it hurt them to put RBCs? Medicine is hard as it is. No need to make the exams more complicated. I doubt my pt is ever going to as me if his/ her normoblasts are going to increase if they go hiking in the mountains +5
mdmikek89  Even in you didn't know what Normoblast means, it cant be any of the other answers. TEST TAKIN' SKILLZ BROS +
nerdstewiegriffin  I can guarantee you this Q was written by some sadistic PhD examiner +10

 -4  (nbme23#27)
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satM elcl iadelgontaurn anc eb edtgerirg by foigenr enaingts nda aaturm

thepromise  I believe what you're speaking about occurs more during hypersensitivity reaction. In this case, there is damage to the endothelial cells, which they also release histamine for vasodilation. which creates permeability for the neutrophills and erythema from the increased blood volume. +13

 +6  (nbme23#18)
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noEpsvele einfbet teh sruvi ni atth teh vursi lliw kloo like the ots,h ltigacaitifn .ionsuf ore,Hwev na edoeepnlv sviur is legnaelry ssel eblsat hnat a andek dcesiaahlor vruis nakde( uesisrv rea gralelyen eahcs.aolid)r

docred123  So do these patients have h.Flu? What was the giveaway? Thanks +1
mousie  I chose Enveloped simply bc it said dies when heated, not sure if there where any other clues to narrow this down or make me feel more confident in my choice but I went with it anyway +16
eclipse  I don't think they expected us to narrow down the answer to a specific virus. Enveloped viruses tend to be less stable (?) than the non-enveloped ones and don't survive as well under harsher environments (outside human's body, heat, etc.) +2
peridot  To add on, I also have no idea what virus this could be but the question stem does say "A previously unidentified virus is recovered from urine specimens" making me think that it's not something we're supposed to have know about, unless I'm totally understanding it wrong. +1

 +7  (nbme23#49)
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Aeosdnngr uceas .cena sesoorteTten is a etertb rwasen tnah Ansdntraoidleo b/c teh otnsToreseet is isedactsao tiwh b,repytu niAlodoendrtas is omre eaisaodtcs wthi the adranle gsadln.

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

 -14  (nbme23#39)
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cNanii can aecus hprc,ieleaygym gsfluni,h nda oug.t sD'INSA acn ettar o.ugt rnsAiip at ihhg tnoaonetcsincr loas hitisnib eraln porbnrseot,ai ubt ti hsbiiitn eisoernct ta owl selel.v I tewn htwi iprnias ovre cometaphnaine cb/ gtohlauh nhmoietpcnaae is na iencsalag ti asclk if-rtymiatnamoaln ii.vttcay

redvelvet  this is not that question :) +6

 +4  (nbme23#40)
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cicdrgAon to FA, hte solrenpaeln ligantem onsaictn the alti fo het pasceran dna teh cpnsile tryear ;&pam einv

littletreetrunk  The pancreas is supplied by the pancreatic branches of the splenic artery. The head is additionally supplied by the superior and inferior pancreaticoduodenal arteries which are branches of the gastroduodenal (from coeliac trunk) and superior mesenteric arteries, respectively. +11
andersen  FA 2019 page 355 / / +

 +16  (nbme23#24)
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Ptineta ahs pycaolihmyte aver, as neeiddecv yb irysh,cseyroott cyguis,latsrono dan eaaehscdh am;p& sesndiz.i OPE is erdceased edu to o.cehyryrstoits ecearesdD LPA oudwl aciitnde CM,L ont PV.

btl_nyc  I thought this was CML. What am I missing that would say CML over PV? +4
btl_nyc  Nvm, RBCs go down in CML, but everything goes up in PV. +9
arcanumm  Tricked me. I knew right away that it was PV, but I thought PV would crowd out normal cell creation (e.g. decrease platelets). So apparently crowding out normal cells is just a quality of AML/CML? +1
drzed  More AML. Remember Sattar always stresses that all the myeloproliferative disorders are expansions of ALL lineages, ESPECIALLY "xx" (depends on which one, for CML it'll be granulocytes, for PV it'll be RBCs etc). They're called MYELOproliferative because all the myeloid linages go up, but one will be increased more than the rest. In this case, it is the RBCs. +3




Subcomments ...

submitted by haliburton(209),
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my tosne morf UR:LWDO nasde etaiypg qotimosu = eugedn huot,s shtasotue s,iaa iifpcca ,nadssli inb,arerac ima arcse HA, rtrtrei=lbooa pi,na tjino p,ina clmseu .heac ,ecpaheite rpruau,p sii,esxpat mee,anl tcaoyohpbtoerin lipoka,enue otteecrnaoocmnihn

thomasalterman  Dengue is an arbovirus. The important hints are that she was traveling in endemic (tropical) and that she has **excruciating pain in the joints and muscles**. This is why dengue is aka "break-bone fever" +  
sam  Same vector +  
sam  Same vector +