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submitted by nlkrueger(43),
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.... ldowu ew lyelra aekt eth rdwo of a nferid owh ifdeytnlei t'nca eb nocrfdime? I efle leik sith is iginasemld

lispectedwumbologist  All the other answer choices make you come across as an asshole. Easy way to ace ethics questions is to just not be an asshole +9  
seagull  I would be a bigger asshole when the family came I'n after I pulled the plug...opps...but the friend said +31  
dr.xx  The patient has no wife, children, or close relatives... +3  
nwinkelmann  @lispectedwumbologist this is going to be my technique, because I've gotten a couple of these wrong, but I completely agree with everyone else's sentiments of suspicion of going off what a friend said without any confirmation about state of advance directives, etc. It's really dumb. +3  
paulkarr  With these questions; you have to take what NBME says at face value. If it says no family, he really does have no family. This friend is also claiming that the 78 y/o said this about himself, so we know it's the patients wishes rather than someone else's wishes for him. (A son saying he can't let go of his father yet despite the patient's DNR type of situation). +1  
suckitnbme  I think the point here isn't that we would take the patient off the ventilator because the friend said so. The answer is saying "Thank you for your input, we will take that into consideration." It's completely non-committal. +7  
vivijujubebe  they say no close relatives, which means he could have remote relatives, relatives must be asked before listening to a stranger/friend's words..... +  


How come melanocytes:basal keratinocytes don't also have a desmosomal connection (in addition to their E-cadherin link)?

vivijujubebe  melanocyte is not part of the epidermal structure. they're at the epidermal-dermal junction and they produce melanin which is transported to the epidermal +1  


submitted by johnthurtjr(142),
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'Im not a fan of sgros hpta sgiaem adn istenqsou atth ays "oo,kl ahtw si siht g?ihn"t - hatt disa siinnogmmea rea eth otms cnoomm iranb mortu nad hist rucptie si si a good emxapel of e.on I hda on eadi wtha etseh itsnhg odleok ekli nda gto it ,wgonr t.oo Tkea a ookl at shti neo

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +1  
meningitis  I got it wrong because I didn't see any apparent Dura mater nor other meninges (The veins aren't being covered by any "shiny layer"), so I thought the tumor was coming from inside the brain and not compressing it like meningiomas usually do. +3  
meningitis  But it did follow the common aspect where they are found in between divisions of brain and are circular growths like a ball. +7  
nala_ula  Since it was basically implied that the patient died and "here look at what this is" I thought it was a malignant tumor (glioblastoma)... but I guess it's all about placement. +14  
thelupuswolf  GBM would be in the perenchyma. Devine podcast said if they show you a gross picture of the bottom of the brain then it's a hemangioblastoma bc it's most often cerebellar. But this one wasn't cerebellar so I went ahead with meningioma (FA says external to brain parenchyma as well) +2  
vivijujubebe  GBM would have necrosis and bleeding whereas the ball-shaped tumor in the picture looks smooth and very benign...even tho I have no idea how someone can die so suddenly from meningioma +  
seba0039  Minor correction, but I do not think that Meningiomas are the most common brain tumor; they are the most common benign brain tumor of adults (Pathoma), but I'm not sure if they're the most common overall. +  


submitted by yotsubato(1019),
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This tsinqueo si lthls.bui heT oanmw woldu msto leykli be daenicvtca ot Srept emnop,u llysepeaci fi seh hda a ytnlece.smpo

E iloc is losa an alneuescdpat aiubtercm ahtt scseau ouminnpae, os ttha si emro lilyke OM.I

sugaplum  I agree with you, only possible logic for their answer: the qualifier asplenic makes the "ShIN" pathogens more likely, even though Ecoli can cause gram negative sepsis and DIC. FA 2019 pg 127 Also it says s pneumo causes sepsis specifically in asplenic patients Pg 136 +1  
lmfaoayeitslit  To be honest, the only reason I got this right (because I really was thinking E.Coli as well), is that I ended up remembering the MOPS part of the Sketchy, and I couldn't remember if he said that it was the number 1 cause of all of them or not, and ended up clicking it. It's pretty shitty they don't offer explanations for these. +  
merpaperple  I thought this too but it seems like Strep pneumo is just more specifically associated with infection in asplenic/sickle cell patients than E. Coli is. Just one of those classic associations. There's a sickle in the Sketchy Strep pneumo sketch, vs. no sickle in the E.Coli sketch. +  
drzed  E. coli causes pneumonia by aspiration, for which this patient had no risk factors. For USMLE, if they don't say the patient is vaccinated, you can assume they are NOT. Just because she has a history of splenectomy following trauma does NOT mean she had to been vaccinated--don't fill in the history for the patient, only use the information they give you. +  
vivijujubebe  also DIC more often seen with G- bacteria right???? That's why I chose E.coli instead of S.pneumonia +1  


submitted by johnthurtjr(142),
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29AF10 p 375 no tGtarieolssnanti dbool splupy nda aiarhtyppstmace neotiarvnni:

  • rogFeut -g-&;t leicca re,yrta gvuas iitnoaenrnv
  • gMudti gt-;-& A,SM guvas
  • dtHigun -&t-;g M,AI ecilpv vearniinnot
neovanilla  Don't force it out, you gotta relax and it'll come out naturally ;) +  
mysteriousmantyping  Why couldn't the answer be Inferior rectal nerve since that controls the external anal sphincter? +1  
draykid  @mysteriousmantyping I think this question is looking at complications of T2DM, more specifically diabetic autonomic neuropathy. Patient more than likely has diabetic gastroparesis which may explain his constipation and abdominal distension. +1  
cuthbertallg0od  Pudendal nerve controls external anal sphincter (per FA), and gastroparesis wouldn't have anything to do w pelvic splanchnics but instead vagus nerve... Don't know why pudendal nerve couldn't be right if he was just clogged up from not being able to relax his sphincter anymore ---- is parasympathetic just more likely to be the issue statistically or something? +1  
cuthbertallg0od  Or would losing pudendal nerve result in incontinence... Its never been clear to me if activation/inactivation opens/closes sphincters... +1  
cuthbertallg0od  Just realized that says perineal... whoops +2  
vivijujubebe  External sphincter is innervated by pudendal nerve, more often damaged during labor. DM patients have autonomic neuropathy with parasympathetic/sympathetic nerves more likely damaged +