NBME Answers : thrawn's page

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Catalase and coagulase-positive gram-positive cocci = staph aureus. mecA positivity means the bacteria carry the gene that confers methicillin-resistance, hence MRSA. Of the choices, MRSA is treated with vancomycin.

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thrawn Confused? +1

submitted by thisshouldbefree(51), visit this page

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between macrophages and neutrophils; neutrohpils are more acute. here is long standing :)

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azibird Is there anything else to it? I was thinking neutrophils because they could be filled with diplococci in gonorrhea. +4

nbmeanswersownersucks I think if they wanted neutrophils they would've had to mention something about maybe pus or white discharge but since this is chronic and scarred, its unlikely neutrophils would be present i.e. no longer an active infection +3

cbreland Can't believe this was that simple... +6

thrawn Macrophages activate fibrocytes to be fibroblasts +2

thrawn There is always a means of complicating a thing. +1

jaramaiha Excuse me while I go chase some zebras +6

coco FA2020 p216 chronic inflammation:macrophage are dominat cell outcome:scarring +2

submitted by thisshouldbefree(51), visit this page

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between macrophages and neutrophils; neutrohpils are more acute. here is long standing :)

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azibird Is there anything else to it? I was thinking neutrophils because they could be filled with diplococci in gonorrhea. +4

cbreland Can't believe this was that simple... +6

thrawn Macrophages activate fibrocytes to be fibroblasts +2

thrawn There is always a means of complicating a thing. +1

jaramaiha Excuse me while I go chase some zebras +6

coco FA2020 p216 chronic inflammation:macrophage are dominat cell outcome:scarring +2

submitted by match95(56), visit this page

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Transposition of the vanA gene from vancomycin-resistant Enterococcus is how it transfers resistance. They use transposons which are located on plasmids. If you have plasmid loss, you won't have transposons, and resistance will decrease.

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azibird Why can't this be a point mutation? +6

freenbme23 I don't think that this implies that it can't be point mutation, but rather plasmid loss is more likely. Also, the point mutation Would have to ultimately lead to the plasmid loss. +

thrawn FA says transposition is responsible for antibiotic resistance and plasmids are for transferring the genes of toxins (though UW says also antibiotic resistance). Make up your minds sheeple +2

mariame The most common Vancomicin resistant genes, vanA and vanB are found in a transposon. These have been transferred from Enterococcus to a multidrug resistance plasmid in Staph aureus. the super multidrug resistance plasmid now contains resistance genes against lactams, vancomycin, aminoglycosides, trimethoprim, and some desinfectants. +2

an1 @thrawn I recall that too, but I think it said transposition was antibiotic resistance and UW said transposons was for multi drug resistance +

uasid The plasmid is lost during bacteria replication – when DNA is being replicated, the plasmid is not always replicated and passed on to subsequent generations, especially if there are several generations of replication. +1

submitted by pelparente(31), visit this page

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If it ain't broke don't fix it. The patient is showing improvement and there are no signs of developing drug resistance or unwanted side effects, so maintain the patient on her current therapy.

Typical antiretroviral HIV therapy regime is:

3 NRTIs OR 2 NRTIs AND 1 NNRTI OR 1 Protease inhibitor OR 1 Integrase inhibitor

In this case the patient is on 2 NRTIs (emtricitabine, tenofovir) and an NNRTI (efavirenz)

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nbmeanswersownersucks and here comes my dumbass that read the lower CD4 count as his newer labs (instead of old) and was trying to figure out why his drug combo wasn't working.... +31

vicebm94 same here.. +

thrawn Amused +

kcyanide101 Same here... Thought pt was loosing virologic control, so choose/guessed one of the two options regarding dropping one NRTI 😩 +

freemanpeng May partly due to his CD4# hasnt become normal?(like >500) +

eimal786 how can I get these scrambled comments fixed?// +

drdoom hi @eimal786. you can sign up for a membership here: https://nbmeanswers.com/membership +

submitted by masn8cc(3), visit this page

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Can someone explain how they r/o aortic stenosis? because that could enlarge the LA and give the same sx of hoarseness etc. And the murmur also fits with AS

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bmalamet You would not see a "viable pulsation above the manubrium, which you should not confuse with a "brisk carotid upstroke" associated with aortic stenosis. +2

nbmeanswersownersucks "brisk carotid upstroke" is the description of a normal carotid pulse. Aortic stenosis has a slowly rising/late peaking upstroke since the stenosis impedes flow out of the LV. +9

overa AS affects the LV first. it isn't until later in the disease progression that there will be a significant enough enlargement of the LA to cause impingement of the LA. By the time the problem was that bad there would also be pulmonary findings of backed-up pressure (in my not so expert opinion). +

305charlie94 Can anyone explain why the trachea is deviated in an aortic aneurysm? Made me think of a pneumothorax here +3

baja_blast ^It's basically mass effect. Aortic aneurism takes up space in the thorax, displacing the trachea to the right. Take a look at this CXR: https://radiopaedia.org/cases/thoracic-aortic-aneurysm-3?lang=us +6

thrawn pneumothorax has mass effect to +

leemax severe chest pain -aortic aneurysm +

submitted by enbeemee(12), visit this page

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i get why it's flagellin, but is the specific reason that LPS is wrong is because it's just not how the vaccine is made? LPS would also elicit an immune reaction, right?

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nor16 Lipid A of LPS can be sensed by CD14 of macrophages causing shock, its not a protein, so no immune reaction as in vaccination (humoral, IgG class switch via Th2 and B Cells). +4

eclipse actually they do use LPS as adjuvant in vaccines +3

hyperfukus TLRs recognize common motifs called pathogen-associated molecular pattern (PAMP) in bacteria, fungi, viruses, and other pathogens. TLR signaling in the modulation of innate immunity + adaptive immunity against pathogens, TLR agonists: CpG-DNA, flagellin, and lipid became essential candidates of effective+safe vaccine adjuvants. TLR agonists improve the efficacy of vaccine, reducing TCR-based selection thresholds and enhancing the magnitude and quality of memory T-cell response. +5

hyperfukus some extra info in case they ask another annoying q +5

aturner713 Not sure if this matters for this or not, but Neisseria spp. have lipoOLIGOsaccharide (LOS) and not lipoPOLYsaccharide (LPS) +5

schep I don't understand why LPS couldn't be the answer also. UWorld question ID 45 specifically says that they are using LPS as a conjugate +1

jp1003 I think it's because Neisseria does have LPS. They have LOS instead. +2

jp1003 *does not have LPS +2

thrawn Doesnt matter - we dont necessarily inject the same specie LOS/LPS in a vaccine - anything to make the immune system wake up to a threat +1

an1 The term lipooligosaccharide ("LOS") is used to refer to a low-molecular-weight form of bacterial lipopolysaccharides. But injecting LPS will induce shock and the 'ENDOTOXIN" cascade mentioned in FA +1

submitted by hyoscyamine(59), visit this page

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FA pg.372. Squamous cell carcinoma occurs in the upper 2/3 of esophagus whereas adenocarcinoma occurs in the distal 1/3. Since this was in the mid esophagus, its squamous cell carcinoma. Key feature of squamous cell carcinoma is keratin pearls.

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turtlepenlight can remember it as wearing a pearl necklace (upper 2/3 of throat-ish) +5

baja_blast Patient is also a heavy smoker and drinker. In the absence of GERD this should raise suspicion for SCC of esophagus over Adenocarcinoma. +1

lovebug Is there anyone who can explain about C)Intra-cytoplasmic pigment? what is this?;; +

misrao @lovebug I'm thinking Negri bodies in rabies +

thrawn probably dust-cells (macrophages) +

submitted by dr.xx(176), visit this page

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Hypovolemia is a direct loss of effective circulating blood volume leading to:

A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia
Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction
Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis
Hypothermia due to decreased perfusion and evaporation of sweat
Thirst and dry mouth, due to fluid depletion
Cold and mottled skin (Livedo reticularis), especially extremities, due to insufficient perfusion of the skin

https://en.wikipedia.org/wiki/Shock_(circulatory)

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thrawn Why no sweating? +2

submitted by k_tron_3000(35), visit this page

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Just a random factoid (as far as I know), in patients with pancreatitis the most likely vessel for thrombosis is the splenic vein due to close “anatomic ties” with the pancreas. This would also cause gastro-splenic varices, explaining the vomiting of blood.

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meningitis Also explains the splenomegaly. If you have thrombosed splenic vein, the blood will pool in the spleen, can also cause expansion of red pulp of spleen. +11

pg32 I picked splenic vein because of this ^^ association. However, why is the patient vomiting blood if there isn't a backup of blood into the left gastric/esophageal veinous system? +1

savethewhales The splenic vein drains the fundus of the stomach. So, splenic vein thrombosis can cause gastric fundal varices, which explains his bloody vomit. +4

medschooler1 how do you rule out arteries? +

ac3 @medschooler1 Just my guess, but when answering this I assumed that splenomegaly meant splenic congestion with blood which can only happen if its outflow tract (splenic vein) is blocked. +5

thrawn Arterial occlusion would be mesenteric angina - or the likes thereof. Venous occlusion leads to variceal bleed +

imgdoc You rule out arteries because if they are occluded its an infarction and if they are partially occluded you'll get angina. +

submitted by mattnatomy(46), visit this page

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I believe this is referring to midgut malrotation. Due to improper positioning of bowel (on the right side). Ladds bands connect the large intestine to the liver.

Can lead to:

Volvulus
Duodenal obstruction

3. SMA Occlusion -- I'm guessing based on the answer to the question

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meningitis Yes, the question clicked for me when I realized the ligament was on the RT side instead of LT so I thought of Volvulus. Image of ligament of treitz: https://media.springernature.com/original/springer-static/image/chp:10.1007/978-3-642-13327-5_17/MediaObjects/978-3-642-13327-5_17_Fig3_HTML.gif +6

hyperfukus So Volvulus regardless in baby or adult is gonna cause SMA prob + Duodenal Obstruction: d/t Ladd bands im gonna go back and remember those associations :) +3

pg32 Yeah, recall that the midgut rotates AROUND THE SMA in development. If you can recognize that the ligament of Treitz is on the wrong side (right) then you know you have a malrotation issue. Then you recall the midgut rotates around the SMA and you pick that answer out of pure association recall and get it right. Nice. +3

drdoom ^ linkify @meningitis https://media.springernature.com/original/springer-static/image/chp:10.1007/978-3-642-13327-5_17/MediaObjects/978-3-642-13327-5_17_Fig3_HTML.gif +2

thrawn I believe they discuss bands in the abdomen - see last page of FA GIT patho +

abhishek021196 https://www.youtube.com/watch?v=cxl6pGPLqJg +

submitted by mattnatomy(46), visit this page

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I believe this is referring to midgut malrotation. Due to improper positioning of bowel (on the right side). Ladds bands connect the large intestine to the liver.

Can lead to:

Volvulus
Duodenal obstruction

3. SMA Occlusion -- I'm guessing based on the answer to the question

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hyperfukus So Volvulus regardless in baby or adult is gonna cause SMA prob + Duodenal Obstruction: d/t Ladd bands im gonna go back and remember those associations :) +3

drdoom ^ linkify @meningitis https://media.springernature.com/original/springer-static/image/chp:10.1007/978-3-642-13327-5_17/MediaObjects/978-3-642-13327-5_17_Fig3_HTML.gif +2

thrawn I believe they discuss bands in the abdomen - see last page of FA GIT patho +

abhishek021196 https://www.youtube.com/watch?v=cxl6pGPLqJg +

submitted by link981(208), visit this page

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However weird, you have to respect the patient's beliefs as long as they aren't putting the newborn at harm. In these types of questions you have to build patient-physician relationships because the patient might become offended if you disregard their beliefs. So while the newborn most likely has gas and not "the evil eye", choice E is the least "offending" answer that suggests treatment.

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charcot_bouchard Exactly. If she was cracking the egg on Baby's head u stop her lol (i am cracking up on my own jokes) +6

jesusisking I feel it but dang, she lowkey drizzlin salmonella all over that baby +2

thrawn But what if the next step of this tradition is feeding the raw egg to the child. It happens in some cultures... I think telling her to continue is wrong - catious indifference seems prudent +

kavarthapuanusha I knew this would be the answer , but i dint put this coz i am not crazy !!! Tbh no one asked the physician if she should continue or not ! Thats like an unnecessary addition , may be " i understand your concern , but why dont we try to change the formula" Would have made more sense!! +