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Comments ...

 +0  (step2ck_form6#10)

https://www.mayoclinic.org/tests-procedures/pap-smear/expert-answers/pap-smear/faq-20057782#:~:text=If%20you're%20a%20virgin,lower%20end%20of%20your%20uterus.

Patients often think that not sexually active is only for vaginal intercourse and might not think that it counts. Also HPV isn't the only risk factor for HPV (smoking, fam hx etc.). Obviously the risk is a lot lower but they should still consider getting tested.

drdoom  I’ll take “More unpleasant things about being a virgin” for 200, Alex. +3

 +1  (step2ck_form6#2)

I got this based on the causes of post op fever. Mostly just a guess really.

The 5 "W's"

1-2 Days post op: WIND - Lungs - post op atelectasis

3-5 days post op: WATER - UTI

5+ days post op: WALKING - DVT/ PE

7 days post op: WOUND - wound infections

8-15 days post op: WONDER DRUGs - Drug fever

The question says pt is 3 days post op so I just went with prevention of UTI. Uworld says the best way to prevent UTI is to remove catheter as soon as it's not needed.

medicalmike  Other answer choices can be eliminated as follows: subQ heparin is unnecessary as the patient is now ambulating Patient should stay on furosemide since it appears this is a home med for his CHF Acid suppression is used for critically ill patients (he is extubated and on his way to recovery) Morphine can be continued as this patient just had his chest split open. He will be transitioned to PO opioids prior to discharge. +3

 +3  (nbme18#32)
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I kepdic )E initiinhob fo aNT-F ueecasb I uhtgoth 2 earsy fo rhierdaa sundso ikel IBD ecliscaf(liyp hcrsno seieasD iwhtout ybodol hirareda vs cu which smtu evha dbooyl rai.rd)ah I llsti on'td see yan esorna hyw I dlotnuw ssgue t.tah

tinydoc  Nevermind just saw the "typically relieved with defecation" which is a pretty big indicator of IBS. +5
pg32  I still agree with you though. This sounds like a case of IBD and I picked E to try and tone down inflammation. Giving someone an opiate for intermittent diarrhea seems kind of dumb... +
pg32  Just googled, "Indications for loperamide" and this is what came up: Imodium® (loperamide hydrochloride) is indicated for the control and symptomatic relief of acute nonspecific diarrhea and of chronic diarrhea associated with inflammatory bowel disease. +
gyabo92  lol, I feel dumb. I knew it was IBS (half my fam has it and just manage through dieting). Went into overthinking hyperdrive, and all it was was your standard anti-diarrheal. step has taken away all my sanity. +8

 +5  (nbme23#22)
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usthuR.Hf5o/yI3/tbt/:JUpezmh

MOA fo epstreooom htsoibriin for .MM :LTRD is atht yhet scabyaill lockb eht otmesoopre frmo figoitucnnn so ttah maleymo lcesl c'atn eclyrce onptseir heyt( maek a ont of t)emh nad nweh teyh 'tnca eb leydercc yhte lubdi pu nda htats xtcoi to eth lcel nda ti sdei.

edbony hatt teh nseituoq is aailsybcl nskiga fi het nbiithnioi fo osoetmrospe tnsi pcisfcei to teh aloMyme clsle nda ti iebidnthi htore cl'lse pomeetsrsoo twah dlwou be ?ftcedfee

MHC lssca I si tserpne on lal euaecltdn llecs al(l lslce in the oybd eextcp CRB) nad fucnotin ot erpesnt sgouednneo gaistnne to 8C+D t llecs to eb ydresetod of(r aemxelp iVarl DNA ni an tinceefd .)ellc The wya hyte od sith is yb tkniga teh notperi it nedes ot spnteer nda aeibgkrn ti ownd niot ucmh lrmasel tdipeep hnsica so( it cna ift on teh I.HCM If hist etps swa itdebhiin ni erhto lsecl etnh eth hte otieePsarnnt fo HCM I udlntwo eb blea to etesprn tirhe negtsian to D8C+ T secll dan Nratula lekirl els.cl sa hte usneitoq ilipm.se

Teh usnoqeti wsa eprus rtikyc aecseub if oyu d'nto oknw woh roosteempo btihsrinoi orwk nhet ouy atsrt nooglki fro an renwas taht udolw anelipx how tyeh oudwl lilk uormt sclle as wle.l I tog it grnwo o.to tI rideuqer nkgloewed of eht ywa CMH I enretsps esp.ipetd


 -3  (nbme23#38)
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0n/iia:/lw.nlecCtpwob#!26.csmr0pc/81g0t916h5psw.15Miv//mnt/o.=.hP

Iv'e hda a wdulro q eehrw the rorccet pnseesor saw to vomeer eht eilf psuprot if het tatpnie si idnredteme ont to eb an nogar ovnene.rdo fi het ilafmy si yaitcevl sgiaatn stih ideincso. In my renexepice eht awsrne atth is msto hntseo (nad eylikl aemsk uoy uonssd leik a tselsatc a)hosesl si ullsyau teh etccrro eon no .sNBME I ekcdpi E adn I 'ontd ees hwo tish dfisnre oiopinn no his aeddvnac rcea sciretdive are ta lal vtelnrea fi eth tnipaet by lla ntcuosa ymladilec nad elyalgl is nidcredseo .aedd


 +6  (nbme24#35)
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I to'nd inthk it amttser whtehre ro ton sith aws LAS ( chhiw I ltsil htnki ti ).is Btu thsree alauntsiiscof adn saWekesn dan opyhatr ehtso rae NMLL sn.sig sTheer ooso anmy asyken enqssiuto ni this axm,e tshi tsni noe of .htme


 +29  (nbme24#16)
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ishT suqionet si eryv an,keys tub in sceeesn isht is twahs pihn.pgnea

hTe cadclnaeti loeamrv of teh HPT slngda uirgdn iooydhymcetrt ⇒ ↓ TPH

TPH -ln-lia ryonm: eon:b ↑ vremlao of C⁺²a dna athoePph orfm onnb e--i skdyin:e ↑ ⁺aC² roportsibane dan ↓ OP₄⁻³ -ps bratr-↑ioneo conievosnr fo 5,2 yrovixdHntmaiy D to 152, mrnyayHtixdvoi D (irlClitoca - icatev ofrm) aiv ↑ yaticvti of a-1 Hsloayderxy dfniccyeei

feorhreTe a ↓ PTH lwodu lade ot:

⇒ ↑ ₄⁻P³O ⇒ ↓ a⁺C² ⇒ ↓ 25,1 yrmiHnxdyatvio D

ehT enistouq si yasenk mc(hu klie the rste fo shit ax)me sbuceae neomseo hwo nits osfnuicg yllrae ahdr or in a srhu imtgh kpic hte oniotp C rweeh ohtpahpe is ↑ nda PTH is ↓ UBT ↓ 25 iyhtmaoyvxrdni D

siTh is rowng as oyln 2,51 htxdvinormyiya D uwodl eb ecreea,dds eth csnvsoreoin frebeo itsh rae oned by eth nkis gtsuh(in)l and e.vril

I aeryll iwsh yhte odwul spto inmgak the uotsqnsie gnoiscnuf LEURPY rof hte aeks of akmgni ehtm guif.oscnn tsnI ti unghoe atht we evah ot wokn ihst locuirudsi omntau fo inmtr,oafoin utiowth ahingv htme eitnlnlnoayti gkniam it raehdr yb ngopniti uoy ot 1 saewnr ecihoc ubt iggchnan a tmuein diaetl ot meka you wesnra gow.rn rO niugs a mdnaro ass nenoautmcler ofr a eisaeds to dvioa amgkin it oot epimls (GPNS = fee"ritriolavp N"G)

tinydoc  I literally got this wrong because I had the font zoomed in and assumed the 1 was on the line above like on uworld when it tries to squish the whole title in the same space x_X +1
hungrybox  Holy fuck they got me. They boomed me. The fucking NBME boomed me. +2
graciewacie9  Amen to the PSGN question. They got me on that one. lol +
msw  the psgn question is pinting to rapidly proliferating glomerulonephritis b/c the pt has developed acute renal failure within days of the insult +
msw  *pointing +
snoodle  HOLY GOD MY BRAIN FILLED IN THE 1. i had to read this explanation 4 times to finally see 25-hydroxyvitamin D and not 1,25. F U NBME +1
avocadotoast  this bs is prob why the question isnt on step 1 anymore +
zevvyt  so since conversion of 25 --> 1-25 is disrupted , would 25 be high? I know its not an answer choice, just wondering +

 +11  (nbme21#24)
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iascfrnt ludwo eb a ermo ilrpeharep ewdeg espah

beacss uotwndl eb invavise to het diuunosngrr area i .kthni

usqsumoa cell si orme eyrnlctal teoadlc

ns'atw 010% uers tub tahts hte sbte raenws htlhgous idustp ot vgei 0 symmpsto adn sjtu a ctpue,ri ghontni eilk na tucaal inaclcli craesoin

tsl19  Squamous cell is centrally located and has cavitation, which you can see in the pic. Similar to this one: https://webpath.med.utah.edu/LUNGHTML/LUNG068.html +6
zevvyt  I also didn't choose infarct cuz i think the lung would have a red infarct. +

 +13  (nbme21#30)
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pyTe 1 aiaFmlli iideplDyaism .gp( 49 AF 91 )

iadenercs GT -&-;tg- ainptriastce retpuc Ei / sripurit Xnmdtaans aho HSM

naC eb uedsac yb piLnitrpooe paisel or ronoptAepi IIC yefdcniice

yhet iads ttah LPL is einf so tsi PAO IIC

raienpH epstsreea LPL rofm rpinreaH tfSleua ieMoty no sacV luEtmedihon wlnaglio su to ttes tsi fcnoiunt ni the la.b

I otg ti wgonr oto - Sdtpui Rteo ioziomemanrt crllae nsteQoui.

masonkingcobra  I think you need to know that ApoCII activates LPL not necessarily know the disease +10
yotsubato  Knowing the disease makes it easier to remember the details though +2
pg32  Mnemonic for these 4 types of dyslipidemias and their causes: 1 = LP meaning LPL is deficient (or anything associated with activating LPL, like C-II) 2 = LD meaning LDLR is deficient (or anything involved in interacting with LDLR, like B-100) 3 = E meaning ApoE is defective and 4 for more (VLDL) ("more" just meaning more letters in the cause (VLDL oversecretion)) +2
castlblack  One too many chylomicrONs, two much cholesterol, threE apo E gone, 4 put the fork down fatty +1

 +14  (nbme21#31)
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adihoyrympptairHser gnciaus nebo osseinl si vai stbstlOaeos seinicnrga RNKA L- xepneisrso ot dnib ot AKRN no ltseoaOscts dna nutasltiimg ehtm t-&;--g cni Beno rRtpeoions

pg32  Picked D despite understanding the above ^^ because IL-1 is also known as osteoclast acitivating factor... +8
plzhelp123  ^ I did the same, but it appears that IL-1 activates osteoclasts in multiple myeloma. Which makes sense as that is a neoplasm of immune cells which can produce interleukins. +
caitlyncloy  can anyone explain why this the answer is "PARACRINE" stimulation?? I rule out the correct answer because i was picturing RANK and RANK L binding, which is not paracrine?! +1
caitlyncloy  oh.. it seem RANK L is secreted to activate the clasts.. i was picturing it as RANKL was on the surface of the blast. reference: https://www.youtube.com/watch?v=hOIBRJeetAs +1
makingstrides  If you can, I Would highly recommend looking at the sketchy pharm for this. It explains this well, in my opinion, and definitely helped me. +

 +13  (nbme21#49)
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uapeoNcrith Pain aetrf ktrseo is tlreanc tsPo storek ipan mSyeornd

aducse yb lrctaontelara atamhicl isselno

P.g 054 F91A

chandlerbas  agreed! more specifically damage to the VPL +6
docshrek  Pg. 403 FA 19. +
baja_blast  Both commenters above got the page wrong; it's FA 2019 p. 503. +4
teepot123  looooool ^ what were the odd of both being wrong +
mumenrider4ever  Pg. 515 FA 2020 +
bbr  503 in 2019 Interesting that its seen in 10% of strokes. Starts with allodynia ---> neuropathic pain. +

 +8  (nbme21#10)
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seytinCe iaUrnry snot:Se

noHaxalge ltsCrays

vtisPeoi dpuesorrisitN stte

euD ot a trhieyrdae nbyiiilat to ebrsorab : its,eyCen iinOh,retn ,eLnysi dAn iirngenA ( LACO ) -g-t;-&- lynO Ceeisnty erpesptticia ot eamk ralne snetos gluhhtoa lla acn eb unfod in hte Uerin.

The daoissgin nca eb maed sadeb no teh erhasitctacriC sett tyeh nemdn,eoti hTe eaoHxlgan hasep of the tn,sose dan teh cfat atth sih ebhortr sah a ilsrami nioodctin ( tosnip to eryhraedit )

Tonriyse nda eopprc tdon ucesa nkediy oestns

hhlautgo caimucl is evry coomnm ti sah a efdfrneti ephas nad tsn'i ngaon eb oesptiiv orf nutispsodreri se.tt


 +2  (nbme21#48)
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Ptx raspeap to aehv lesucM stiptcsayi as a esutrl fo MS. ipyctSitas is etredat htiw a msceul nretaxal iekl ecBnfalo hwhic si a AGAB sgio.nta acnaBtohle is a ilihnmteoinmCoc hihwc nac be ueds ot artet rynUari tdufyisncon in Mpultlei scleriso.s utb het neitoQus saks twha louwd lphe rteta het ticysaipst.

athenathefirst  Why not mecamylamine? +
athenathefirst  Is it because it's MS? So for sure need a GABA agonist +
kevin  Never heard of mecamylamine, just know UW and FA say Baclofen, GABA-B agonist for spasticity. It's not solely because it's MS, it's just the drug they want us to know for specifically spasticity +

 +5  (nbme21#48)
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xtP paaersp to evha ceulMs taycpssiti sa a ltseur of MS. cStiypsait is ertdate whti a ulesmc lxnatrae ekli oaflenBc ciwhh si a BGAA stoigan. halBotecan si a ocimeionnthClim hcwih nca be esdu to etart aniryrU tfuycnnosid in etullMip roesssi.cl tbu teh oteuinQs akss twah ulowd ephl etrat eth aitc.ssypit

sbryant6  To remember Baclofen is a GABA agonist and muscle relaxant, I always think of the "Greek Baklava". Greek for GABA, Baklava for Baclofen. +4
sahusema  Also, acts on GABA receptors specifically in the spinal cord +2




Subcomments ...

submitted by step_prep(57),
  • Patient with risk factors for spastic bladder (MS) has presentation consistent with urgency incontinence (urge to void immediately with loss of urine before reaching the bathroom at times), which is caused by detrusor hyperactivity/instability
  • Stress incontinence: Loss of urine with cough or increased abdominal pressure, caused by urethral hypermobility or sphincter deficiency
  • Overflow incontinence: Incomplete emptying of bladder leading to leak with overfilling; patient would have increased postvoid residual

https://step-prep.org

tinydoc  But why is the answer not MS? Is it just because the way the question was worded asked what is the cause of the patients symptoms as opposed to what is the underlying cause? +1  


submitted by tinydoc(233),
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I cpekdi )E iihtinbion fo aT-NF beecsua I othghut 2 esyra of eaahrird onsusd elki BDI ipleacls(cify hrosnc Disesae hiwoutt dybloo earriahd vs uc ihhcw smut ahev oobdly a)iarhd.r I tilsl dnto' see yna rsonea why I uodlnwt segus .that

tinydoc  Nevermind just saw the "typically relieved with defecation" which is a pretty big indicator of IBS. +5  
pg32  I still agree with you though. This sounds like a case of IBD and I picked E to try and tone down inflammation. Giving someone an opiate for intermittent diarrhea seems kind of dumb... +  
pg32  Just googled, "Indications for loperamide" and this is what came up: Imodium® (loperamide hydrochloride) is indicated for the control and symptomatic relief of acute nonspecific diarrhea and of chronic diarrhea associated with inflammatory bowel disease. +  
gyabo92  lol, I feel dumb. I knew it was IBS (half my fam has it and just manage through dieting). Went into overthinking hyperdrive, and all it was was your standard anti-diarrheal. step has taken away all my sanity. +8  


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iDd nynaeo seel go wnod eth: ses'h hinvyptosee os baemy slhl'e get toheuresaw dirschreeinf nmydsroe aecuebs ngihtno lsee si gnmika nssee to me ta sith p?nit??o rtoeu -

ursTn ,out eseevr imralaa anc ucsae vcausodliaarcr lecpaosl dna tp.snhonioey

redvelvet  me too :( +1  
abigail  me three :( +1  
yex  Me four :-/ +1  
link981  Slowly raising my hand as well +1  
tinydoc  Sammmme +1  
bullshitusmle  same here!!!:@ +1  
usmlecharserssss  patient has malaria with obvious picture and clinic, i answered because only thing associated with liver was hypoglycemia +12  
aisel1787  me five( +  
myoclonictonicbionic  I was thinking that she is hypotensive which can cause an infarct of the pituitary (since pituitary is growing during pregnancy) and therefore she'd have secondary adrenal insufficiency. +1  
alexxxx30  sammmeeeee +  
snripper  Dumbasses unite lmao +  
usmleaspirant2020  lol saaaaame! +  
usmleaspirant2020  lol saaaaame! +  
anechakfspb  me also :/ sitting there trying to figure it out during the test I thought I was so smart too - like "wow nbme, way to tie in micro and endocrine, not getting me though!" ... i was wrong. +1  


submitted by yotsubato(1041),
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Tshi is a oseinqtu obaut einptta aypvci.r ehT netpati rhee si teh dch.li hTe pyrxo for eht inteapt si eht ohemrt nad rethfa. They stum nwok hswta row.ng eirstS adn homret are sjtu ololoyk,so and nreastp may ont wnta ot tell ethm itd(usp I ,wkon utb )hravteew so uyo sedn tehm tuo nda tehn lelt het tenarps eth ntitua.sio

dr.xx  agreed +  
thepromise  so you're not gonna conceal the abnormality and act like its their fault? since they touched it last +28  
tinydoc  How on earth would they expect the parents to conceal a malformed upper extremity from the grandmother and the aunt of the child in a family that is close enough to allow these people to be in the room during the delivery. As always the ethics questions seem to make sense in retrospect, but always seem to have a ludicrous action on your part that you wouldnt do in practice. +10  
llamastep1  It's not just conceal but it's a private and sad moment, gotta give the parents some time to process it. +5  


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fI hte aorlmaybnti saw omignehts eomr feli aheeinngrtt, lonw'dtu eth itfrs oaticn eb to llac het rtciid?paaein I was ikn,htgni milb trteexiym mhtig neam hesntmigo eles meor ioreuss asw nhgipapen oot -t;-g& ende rcdteainpiia rhigt aayw ot dx.

tinydoc  I thought about that but then I ruled it out as with the NBME ethics questions the answer is almost never to defer to someone else. The question doesn't ever tell you what type of doctor you are for you to be referring to a different more specialized physician. Also I assume that they think if there was something wrong you could handle it. +2  
llamastep1  Out of all the questions (UWorld,NBMEs etc.) I can only think of 1 question where you had to refer. +1  
targetmle  even i thought pediatrician should be called as after all, every newborn is screened by pediatrician and in this case, he had abnormality! i still wonder why would gynaec comment on that! +  


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kniS drsvepoi talsniouni and vtsenrep ehta .slos hsTi a'snpttie byod lwli apncmetsoe rfo irenesdac eatr of eaht slos by igcrsanien tcmbliaeo .etra

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? +24  
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. :) +2  
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. +  


submitted by mousie(220),
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ruYo iauittrpy tltrocapo escll prpherohtyy drginu yrcgnpaen ot ouepcrd saiircengn umotans of ontlpirca - atrp fo eth pioohylpohgayst fo enhesSha' m.reo.ydn.s icdarnese oldob lsso gdurin lriveedy can cesau hsimeicc csorisen fo tyrtapuii

tinydoc  I thought the elevated Estrogen and progesterone depress the function of Prolactin until delivery. I guess you needed to know that it decreases its function by downregulating receptors or something as opposed actually decreasing the prolactin production. I picked gonadotrophs. This was a fair question but I reasoned it out and arrived at the wrong conclusion. +7  
maxillarythirdmolar  Specifically, the estrogen is stimulating lactotrophs as progesterone is preventing the prolactin from actually working on the breasts. So it's the estrogen that is stimulating the lactotrophs to grow, and you would see the effects of this growth if it weren't for the progesterone preventing the action of prolactin (their secretory product) on the breasts. +9  
dul071  why not somatotrophs. she's understress. wouldn't that increase the production of GH +  


submitted by notadoctor(159),
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LES is atecdoasis htwi defieccniy of relya mepnometcl esrt.gipo(ne Cq1, ,C4 .2C) FA( ,19 .pg )246

tinydoc  Am I the only one who has never heard of C1Q? +27  
llamastep1  I knew SLE is related to low complement but when it talked about a "mutation" it threw me off. +1  


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A asobltmonr is an uaterimm BR,C so ist' dteelvea ni tastes fo dasnicree mehsaoespt.oii

sympathetikey  Don't mind me. Just sippin my dumb ass soda over here. +63  
someduck3  The term "Normoblast" isn't even in first aid. +36  
link981  NBME testing your knowledge of synonyms. Have to know 15 descriptive words of the same thing I guess. +19  
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. +18  
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 +6  
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 +6  
nerdstewiegriffin  I can guarantee you this Q was written by some sadistic PhD examiner +13  


submitted by usmleuser007(397),
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PIP fcfeesdite-s: + acsnerdie krsi orf C. idff + cnsdIaree rksi ofr resp nniitfseoc + cna cuesa iynphmagaeso + reedacse ositbapnor fo (+,2aC g,+M2 &pam; )niro + ndeeriacs kisr fo oeotcosroipt hip trrcaeufs (dt/ owl remsu ccm)liua

imnotarobotbut  That's not the right answer tho, the answer is the binding of PGE to it's receptor +  
tinydoc  Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1  
maxillarythirdmolar  Keep it simple, stupid. +1  
roaaaj  @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +  


submitted by welpdedelp(229),
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,omrecsHsiohamto aak oben"rz e"tsbadi.e Coantn eb iAddson due ot hte ermhelcgiyapy dan amlonr BP

alexb  I missed this bc didn't notice it was a middle-aged guy w/ just 3 year hx of Type 1 DM. +2  
tinydoc  I got it mixed up with primary adrenal insufficiency and the acth ⇒ hyperpigmentation. +12  
maddy1994  testicular atrophy &hepatomegaly helped me out to eliminate the options..when i was left with ferritin and saw pigmentation it clicked that it is hemochromatosis +3  
krewfoo99  Symptoms of Darkening of skin, liver dysfunction, diabetes, with testicular atrophy will always be hemochromatosis +3  


submitted by brethren_md(90),
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lsiaCcs elesp pneaa in the atipte.n teaissonC fo ehgibrtan aessuc onuantrcl hayiopx and msstyeci srhereypr/iyth/cotsadnheimnnud teahd anc se.tiprs 2aOP is noraml dnrigu dya dna caeedesrd nirdug spisedoe nad ta h.ting ysalCslical snee ni bOsee eaistptn shcu as het tnieapt ni teh iqousetn sm.et

tinydoc  Caused a cessation of breathing rather than a ↓ in lung volume although a patient could develop an obesity related restrictive lung disease thats not whats happening with this question. +2  
sunshinesweetheart  p 665 FA 2019 +1  
syringomyelia1  p 679 FA2020 +1  


submitted by step420(34),
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itseuQon rttyep uhmc si nagsik atwh peyt of vruis is a,leMsse ichhw is a evigetNa sANsR isuv.r

dragon3  is the AIDS to indicate that he can't get live vaccinations? +1  
tinydoc  Yep, also his unimmunized cousin points you to the fact that he got it from someone else who was unimmunized. +  


submitted by tinydoc(233),
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Tihs stnuqioe is evry ,sneyak tbu ni senscee shit si awtsh ihpnpng.ea

heT lcaaitdnce amvorle of het PTH naglds rdigun eottmycrhyodi ⇒ ↓ PHT

HPT -:orimnla-ynl bn:oe ↑ remvlao fo ⁺²aC adn hpaoPhet mofr -e-n onib kenydi:s ↑ ²Ca⁺ otrarpneiosb nda ↓ ⁻³₄PO pnbior -oesr-ta↑ roisnencov fo 5,2 ydvamotnxiyriH D to 215, doxymtnviyrHia D oiica(llCrt - caveit fom)r aiv ↑ ittycvia fo a1- xrladsyeyHo fiydieencc

horeeerTf a ↓ THP uowdl elda to:

⇒ ↑ ⁻P₄O³ ⇒ ↓ aC⁺² ⇒ ↓ 2,15 nHxivmtoidyray D

eTh oqsetniu is yanske muhc( ikel hte rtse fo hsit xaem) ueescba oeosnme who stin nficguso lrelya rahd ro ni a hurs hgitm pcki the ponoti C herew ahoptpeh si ↑ adn THP is ↓ BUT ↓ 25 ymhixvinoadytr D

ihsT si ongwr sa lyon 521, hmirinoyyaxtdv D dlouw be ac,edsedre het isceosronnv erfebo sith rae node yb hte insk h(sunt)gil nda rve.li

I eallry hiws thye uowld sopt niakgm teh nesoisqut siunoncfg ELYRPU for eth seak fo iknmag tehm cufisgn.no tIsn it ungoeh ttha ew aevh ot ownk hsti ruuscioldi onutam of tnrnimaoi,fo thuotiw ihnagv ethm lttilinonnaey ignakm it aherdr yb pnitigno yuo to 1 arnsew ohecic btu nignaghc a untiem leidat ot maek you rawnes ogr.nw Or ngsiu a raondm ass cmeutnelorna fro a desseai to vioad iagknm ti oot melisp (SNGP = poirelt"riveaf "N)G

tinydoc  I literally got this wrong because I had the font zoomed in and assumed the 1 was on the line above like on uworld when it tries to squish the whole title in the same space x_X +1  
hungrybox  Holy fuck they got me. They boomed me. The fucking NBME boomed me. +2  
graciewacie9  Amen to the PSGN question. They got me on that one. lol +  
msw  the psgn question is pinting to rapidly proliferating glomerulonephritis b/c the pt has developed acute renal failure within days of the insult +  
msw  *pointing +  
snoodle  HOLY GOD MY BRAIN FILLED IN THE 1. i had to read this explanation 4 times to finally see 25-hydroxyvitamin D and not 1,25. F U NBME +1  
avocadotoast  this bs is prob why the question isnt on step 1 anymore +  
zevvyt  so since conversion of 25 --> 1-25 is disrupted , would 25 be high? I know its not an answer choice, just wondering +  


submitted by jambo2222(29),
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Its’ an .oeasaosctrmo aaorScm = naetgemsouoh mts.e sIt’ in eht lgse os hnkit ohw a DVT osge ot .gnul Saem .iade

tinydoc  Perfect way to remember it. Thank you! +9  
chandlerbas  Iused the mnemonic PB (lead) KeTtLe....looking at the stem it said "osteolytic mass" meaning that it has to be either Breast, Kidney, thyroid or lungs. none of the rest are options leaving lungs. but jambo2222 very noiice that works too! +1  
jajajaja  @chandlerbas I think you might be using the mneumonic backwards- PB-KTL is for primary cancers that met to bone. For example, a primary lung cancer can met to bone and cause an osteolytic lesion. But in this case the primary cancer is the osteosarcoma. Meaning that the mneumonic doesn't actually apply to this question +14  
chandlerbas  ya you're right good stuff!! I dont know why that made sense during the question...anyways to add to the other comments...osteosarcomas are aggressive and 10% metastasize to the lungs via hematogenously at the time of diagnosis. +  
mtkilimanjaro  just to add, in terms of venous circulation everything goes to heart via vena cava and then to the lungs. The only way the bone would metastasize to these other structures would be if it continued through arterial circulation without seeding, which seems unlikely. The only ones that spread to the liver are from the PORTAL venous system, aka not bone only colon etc. +1  


submitted by beeip(124),
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siTh sha eneb a houtg pccoent orf me to et,g utb I nkhti m'I yalnfil :ereth

heT emst si csnidigber rmyripa ranlaed su,icfiifcenyn or Ads's.odin

  • HCAT is nbgie dvepcoreor-ud to utlsmitae eht naldasre ot purcoed ,olrcisto utb hety 'cnta nrdesop, terihe ude ot oytprha ro tetscoruind (,BT imaumnu:ote ,DR4 e.t)c
  • Teh sfrti 13 oainm sciad of ACTH nac eb cealdve ot rofm αM-,HS cihwh ilutamsets yem,ctoslane nsauicg ntotyargpeiiehmnp
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


submitted by jotajota94(14),
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gihH ueoglcs ladse ot omre inuinsl iudnotoprc ni eht tesuf (llerac tath eth nemrooh isiulnn si iala)cnbo -t-&-;g glrea uefts l1,-)b;z--(to&9g msbrolep in ablro.

tinydoc  I thought that was technically a problem with the fetus and wasnt considered an obstetric complication. +3  
shieldmaiden  Because shoulder dystocia is the obstetric complication, it describes the event of the baby getting stuck in the mother's pelvic bone and regressing a bit into the canal. As a consequence, both baby and mother can suffer complications like Erb's palsy for the neonate and post-partum bleeding for mom. +  


submitted by celeste(83),
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ehT ealtosincntol fo mymsspot sodsun leki oubtsreu ss.iclrseo aarCidc oaaymdombhr is a arer innbge roumt tath si qryluetefn iosatdecsa thiw suutbore sse.roicls

tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +15  
tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +2  
arlenieeweenie  He also has seizures and pink-yellow papules, which I think they're trying to describe one of the characteristic ash-leaf or shagreen patches (doesn't sound like either of them to me lol) but that all points to tuberous sclerosis +  
pg32  @arlenieeweenie I think they are actually trying to describe angiofibromas that appear on the face in tuberous sclerosis, though I still think their description is pretty bad haha +5  
lovebug  Tuberous sclerosis. mnemonic : HAMAR(->Rhabdomyoma)TOMASS. FA19 page.513 +  
naarim15  the pink/yellow papules are adenoma sebaceum - "reddish nodules in a butterfly appearance areound the nose and cheeks, acne-like appearance" https://next.amboss.com/us/article/Rk0lnT#Z018f418df303f0090d6f81837408e107 +  


submitted by celeste(83),
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heT oconesntalilt of tpmmoyss unodss ikle suoubtre s.lssirceo aiarCdc adboaymmhor si a raer nnibge uormt tath is urtleneyqf oaaeitcssd tihw ubtrouse r.osliscse

tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +15  
tinydoc  Cardiac Tumors in adults -- usually myxoma Cardiac tumors in kids -- usually Rhabdomyoma ( ass. w/ Tuberous Sclerosis. ) --> its in the first aid rapid Review +2  
arlenieeweenie  He also has seizures and pink-yellow papules, which I think they're trying to describe one of the characteristic ash-leaf or shagreen patches (doesn't sound like either of them to me lol) but that all points to tuberous sclerosis +  
pg32  @arlenieeweenie I think they are actually trying to describe angiofibromas that appear on the face in tuberous sclerosis, though I still think their description is pretty bad haha +5  
lovebug  Tuberous sclerosis. mnemonic : HAMAR(->Rhabdomyoma)TOMASS. FA19 page.513 +  
naarim15  the pink/yellow papules are adenoma sebaceum - "reddish nodules in a butterfly appearance areound the nose and cheeks, acne-like appearance" https://next.amboss.com/us/article/Rk0lnT#Z018f418df303f0090d6f81837408e107 +