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Welcome to yotsubato’s page.
Contributor score: 968


Comments ...

 +1  (step2ck_form7#2)

The indications for blood transfusion for pelvic fracture patients are systolic blood pressure of <90 mmHg, heart frequency >130 bpm and clinical symptoms of shock. In an emergency, combined transfusion of red blood cells, plasma and platelets (6-4-1) is preferred (19).

So...... This question is bullshit?

study_dude_guy  I spent way too long trying to find this paper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394148/ The flow chart is the first figure In major trauma, you give 1-2 L of fluid and check for response, if they are still hypotensive you give blood products. +
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +
seagull  This is a question of elimination. A) Epinephrine would increase his heart rate which is already at 130 B) No idea what this is- cross it off C) Recombinant factor 8 - tx hemophilia A D) reverse anticoagulation but not commonly used. PCT is used now. E) PT is hypotensive and actively bleeding in chest - makes most sense +

 +0  (step2ck_form7#27)

Medications that cause direct esophageal mucosal injury include the following.

Antibiotics — Tetracycline, doxycycline, and clindamycin have been associated with esophagitis due to their direct irritant effect. (See 'Pathogenesis' below.)

Anti-inflammatory medications — Aspirin and anti-inflammatory agents can cause severe esophagitis, esophageal strictures, and bleeding [1].

Bisphosphonates — Although the incidence of side effects with bisphosphonates is low if proper administration instructions are followed, esophagitis, esophageal ulcers, and strictures can still occur [3-8]. (See 'Prevention' below.)

Among oral bisphosphonates, risedronate appears to have minimal gastrointestinal toxicity, and, in clinical practice, some patients have fewer gastrointestinal side effects with risedronate as compared with alendronate [6,7]. In an endoscopic study of 515 postmenopausal women receiving daily risedronate or alendronate for two weeks, significantly fewer gastric ulcers were seen in the risedronate group as compared with alendronate (4.1 versus 13.2 percent) [9]. The side effects of bisphosphonates are discussed in detail, separately. (See "Risks of bisphosphonate therapy in patients with osteoporosis".)

Other — Other causes of medication-induced esophagitis include potassium chloride, quinidine preparations, iron compounds, emepronium, alprenolol, and pinaverium [10].


 +2  (step2ck_form7#37)

Doxazosin is not given because he has a history of orthostatic hypotension.


 +0  (step2ck_form7#19)

Transsphenoidal surgery should be considered when:

●Dopamine agonist treatment has been unsuccessful in lowering the serum prolactin concentration or size of the adenoma, and symptoms or signs due to hyperprolactinemia or adenoma size persist after several months of treatment at high doses.

●A woman has a giant lactotroph adenoma (eg, >3 cm) and wishes to become pregnant even if the adenoma responds to a dopamine agonist. The rationale for this approach is that if the patient becomes pregnant and discontinues the agonist for the duration of pregnancy, the adenoma may increase to a clinically important size before delivery.


 +1  (step2ck_form7#31)

Kind of a bullshit gotcha question.

THe pain started after she started moving furniture = she was active = she has a chance of pulling a muscle = costochondritis

Even though she is a walking talking risk factor for PE...


 +3  (step2ck_form7#5)

Lactose Intolerant I guess? Not Celiac. Kind of a bullshit question.

study_dude_guy  Had the same reaction as you and then I learned that AA is a buzz word for lactose intolerance "African American and Asian ethnicities see a 75% - 95% lactose intolerance rate, while northern Europeans have a lower rate at 18% - 26% lactose intolerance" +
seagull  I also choose Celiac's. "BuT RaCe AnD mEdICiNe DoN't Go ToGeThEr". +
hayayah  I think a key part to differentiate between celiac's and lactose intolerance in this question isn't race, it's because of the part that says "he occasionally had diarrhea after meals since 12 years old and then it got worse since starting college". If he had celiac's he'd have GI symptoms (i.e. diarrhea) any time he ate something containing gluten (which would be every single time he had a meal) since he was 12. You'd also see signs of fat or vitamin malabsorption in celiac's patients and other autoimmune symptoms. Whereas in lactose intolerance, it's much more likely he'd once in a while eat a lot of dairy and have his symptoms triggered, and then he starts college and has even less of a well rounded diet and so his symptoms get worse. +2

 +0  (step2ck_form7#2)

Your vascular surgeon may recommend you have a carotid endarterectomy if you have: A moderate (50-79%) blockage of a carotid artery and are experiencing symptoms such as stroke, mini-stroke or TIA (transient ischemic attack). A severe (80% or more) blockage even if you have no symptoms.


 +1  (step2ck_form7#3)

Lets take a picture with a potato, JPEG the hell out of it and throw it on an exam .


 +2  (step2ck_form7#8)

Ill be the Cowboy.

Diagnosis: ALS

Multispike and fasciculation potentials Complex, repetitive discharges occur in ALS of long duration, as they do in other chronic neurogenic atrophic conditions. These are regularly discharging multispike potentials that are time-locked. Other than an EMG finding associated with a chronic neurogenic atrophic condition, this finding has no other unique significance.

Fasciculation potentials are seen frequently but not invariably in ALS. Their presence is not specific to ALS; they may occur in other conditions, some completely benign.


 +1  (step2ck_form7#29)

Note: Oral Amoxicillin is not given. It has to be IV pennicillin.


 +1  (step2ck_form7#10)

Welcome back to Step 1 minutae... Useless crap they make us memorize, hell not even memorize.

athleticmedic  I had no idea what this question was trying to get at. It makes sense looking back now, but at the time I had no idea what they were talking about. +

 +1  (step2ck_form7#7)

You know they could throw us a bone or something... Tell us the uterus is boggy at least, or hard, or ANYTHING AT ALL REALLY....

saffronshawty  They mentioned that the uterus is 3 cm above the umbilicus which is an indication that it's enlarged and hasn't returned to the normal post-partum size it should be, which is at the level of the umbilicus +/- 2 cm. +

 +1  (step2ck_form7#38)

. The immune response to M tuberculosis is T cell dependent. It comprises not only the conventional CD4 and CD8 T cells, but also γδ T cells and CD1 restricted T cells. γδ T cells recognise phospholigands and no presentation molecules are known thus far. CD1 restricted T cells recognise glycolipids, which are highly abundant components of the mycobacterial cell wall. Although different T cells are required for optimum protection, the immune mechanisms known to have a role in acquired resistance can be associated with two major mechanisms: (a) activation of macrophages by cytokines; (b) direct cytolytic activity. In vivo granuloma formation, which is central to protection, is induced and sustained by cytokines. Mycobacteria are contained within granulomas and in this way are prevented from spreading all over the body.

So it looks like we just need to know this. Nevermind the fact the question stem doesnt even hint at any congenital problem in the girl....


 +0  (step2ck_form7#20)

Shitty heart sounds strike again. Totally thought the artifact in the recording was a continuous machine like murmur...


 +4  (step2ck_form7#3)

This one made no sense. Celecoxib is already the strongest NSAID. I would rather give Dexamethasone. Which works along a seperate mechanism of action.

jaypat  Indomethacin is typically the first choice NSAID for acute gout flares. Then glucocorticoids. Lastly Colchicine +
seagull  I also choose steroids since they were on a NSAID. fml +
creamy  Naw dawg. Celecoxib has anti-inflammatory efficacy hence the categorization as a NSAID. In fact, gout patients treated with Celecoxib have the same treatment response as Indomethacin. Celecoxib is actually listed as an alternative to nonselective NSAIDs for acute gouty flares. This was just a bumbass question. +1

 +0  (step2ck_form7#23)

Weird answer to a weird question. "She(the girl herself) doesnt understand why she does these things" made me think of some sort of Mania component.


 -1  (nbme24#45)
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oClo nroehta uqsieton tenka rmof eth lsti of sgnthi tno in FA

charcot_bouchard  Actually it is in FA. FA 19 Page 100 - Antigen loaded onto MHC1 in RER after delivery via TAP transporter.... Remember FA is that friend who always say I told you so. +18
yotsubato  But not in this context +5

 +4  (nbme24#6)
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TAL dan TSA are enmzesy hwntii yspeoatceth. tuohiWt tyeehtocpa mad,eag uyo tnwo haev .vasoieltne

iklnleAa eptaosphsha is ntsrepe ni all tsisues uurthogtho het tiener od,by btu is acluplyritra atctcneeornd in het ,elirv bile u,dtc kyni,ed ,enob nsatieitnl ocumas dan aaecln.tp


 +12  (nbme24#49)
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dClo rai eundsic mtshaa tsakct.a

Dngsreecai ousrec oadl wont pelh

Tnkgai isosdert si oot mhcu rof wno

oniMgv bcka to eht osmrd is otn alvieb

rAi caenrels ndto okwr hgonue

Dnot teg dri of hte Gdoo eoBy

mSgonki norosdi is snisitgugd

sherry  Stress can actually be a trigger for asthma. I think the problem here is that she has alwasys carried a heavy course, while the disease just started recently. +7
medguru2295  Stress makes asthma worse. Therefore, keep doggo for stress relief! +
qiss  Also her symptoms started 3 months ago and she moved in with a roommate who smokes indoors 3 months ago. +2
jrish  But wouldn't the smoke on the roommates clothes still cause significant asthma problems? +

 +0  (nbme24#13)
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hWy si hte pteitan ton ni pi.na I lnwdtuo pextce drtnIarecaec aneihr to eetsnpr tihw zore ,naip tbu 1 keew fo snitoncpiota and isgwnle.l

yotsubato  Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Like really? Why is he not in pain? +1
medschul  I thought that inguinal hernias were reducible? +
fahmed14  could be a femoral hernia as they are more likely to cause incarceration. They do, however, present more often in females. (FA 2019- 364) +1
wowo  incarcerated, not strangulated, thus no pain as there's no serious tissue damage/ischemia. Incarcerated hernias may progress to strangulated in which case he would have pain Under section, "complications" https://www.amboss.com/us/knowledge/Inguinal_hernia +5

 +1  (nbme24#41)
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diKn of ircykt not.usqie The zstpnyohoei ear uiolrnehqco iastetns.r Btu het eeipcss may ont b.e

P. urmacaipFl is rtneiasst nda okosl eilk a ana,abn btu yuo dnot wokn fi the liaraam ni teh CBR is auicamfprl ro tno.

tyrionwill  whether resistant or sensitive, depends on the region, not on the species falci coming from Hatii could be sensitive +

 +6  (nbme24#29)
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lyimodA A : sene in ncrhcio faytnolmrima notoc,iinds odnpetsiio of oaylmdi ni isestus

B2 :nliogomirbclu edcosaitas twih SRDE nda ongl trem yiidsasl

arnmtfoelieNu r:eiontp Fomr hte ntkloyoceset of esournn (in ltehyha i)idavunldsi

neirnsPeil: asaitscdoe with miiaallf elhrseizma diseesa

sunshinesweetheart  neurofilament also seen in neuronal tumors i.e. neuroblastoma +

 +1  (nbme23#49)
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hAhluogt eneocpmiantah ly(n)lToe si ton drisendoec an SAIN,D it oto yma rpokvoe na pis-rkiaelni isstieynvi.t

meningitis  For that same reason (not an NSAID) it doesn't reduce inflammation so it cant be used for Gout. +5
meningitis  And I think Indomethacin is associated with anaphylactic reactions in patients with aspirin-sensitive asthma and aspirin allergies. Can anyone confirm? +
link981  How many other's like me didn't see "allergic to aspirin"? FML +3
hyperfukus  OMFG me too i just got so mad and questioned my whole life at least its cuz i can't read not bc i don't understand :((((( +1

 +5  (nbme23#27)
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nerCilh"d ithebix iboarhve ncgtnnoeriu iwth ietrh aeg dan mvedet"opnle ni uaxles .baues

tyrionwill  mostly the age difference exceeds 4 years trigger so called "incongruent with their age". age incongruence plus signs of being forced, like this case which the 4-year-old boy was found crying, lead to suspicious more on sex abuse than sex play. +2

 +36  (nbme23#10)
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Wsa it usjt e,m or ddi "eag ta tnseo ni s"ayer ppaare ITHRG vbaeo eth nmbrue of taspe,itn errhta nhat hte .anme Which uofcdnes em for a odog 3 seuim.nt

fulminant_life  Definitely was the same for me. I was so confused for like 5 mins +13
d_holles  dude i almost didn't get the question bc of this ... i thought the age of onset was the actual age of onset (36) +7
mellowpenguins  Are you serious. NBME strikes again with shitty formatting. +7
yex  OMG!! Now I just realized that. Super confused and also thought onset of age was 36. :-/ +5
monkey  what is 36 supposed to be? +1
thomasburton  Think the number of people in that group +5
paulkarr  Yup...was looking at it for a good 3 min before just doing the "fuck it..it's gotta be 99" +4
arcanumm  Age of Onset is the Title of the table, which I didn't figure out until after exam was over. What terrible formatting. +3

 +15  (nbme23#11)
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eYha ues,r tels evig the uyg owh nsawt ot ekep shi cikd nowrgik dan eb cavrttaeit wrostad wemno ernesatiFdi nad yctplelome niru hsi sttsreeoteno llevse and ievg him a mpli cikd, anm sobb,o dna cdserdaee apceomefrrn ni .trspso

tsiSeomme the BENM lyelra jstu smkae me ask ?hyW

aoilTpc iidmnlxoi uwdol be yaw rtbete tbu no yeth wotn tup thta as a cichoe

anjum  To clarify: the lack of DHT production caused by finasteride leads to gynecomastia and ED. The other options are synthetic androgens. Totally agree that this question goes against the benevolence vs. maleficence that we've been taught in medical school +

 +0  (nbme23#23)
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renAt ew TON udpssoep to ues putmariorip ni dol o?peepl

amirmullick3  Who said not to use it in old people? Remember "I pray that tio can breathe soon" and tio is an old uncle in spanish but its also the other drug, tiotrropium. +2
drdoom  discussion of anticholinergics & elderly also discussed at some length (but different context) here: https://www.nbmeanswers.com/exam/nbme22/1288 +
guillo12  Ipratropium does not penetrate the blood-brain barrier, so I think this is why it can be given to old people. https://www.rxlist.com/duoneb-drug.htm#clinpharm +4

 +15  (nbme23#9)
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iTsh si a nustoqei baout ptitnae cy.aprvi ehT atpniet rhee is teh cdl.hi eTh oxypr fro the tatpnie si eht eotmhr nda hefta.r yTeh utsm okwn hawts nrwg.o etisSr dan ormhte rae jtsu ,koolyoosl nad erpatns amy ton awnt to eltl meht u(ptisd I n,wok btu e)vhretwa so yuo sden temh out dna thne etll teh etpsran eth ntat.uisoi

dr.xx  agreed +
thepromise  so you're not gonna conceal the abnormality and act like its their fault? since they touched it last +25
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. +9
llamastep1  It's not just conceal but it's a private and sad moment, gotta give the parents some time to process it. +4

 +5  (nbme23#12)
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umuMrr hatt si ldeour wthi ceduedr vsnueo rnruet &=tg; pctpriHyhroe ayhotacdomiryp

OCHM is edu to oasmittun onneigdc arcrsmeeso uchs as oinysm gnibndi reonipt C adn ebta nosiym vyeha ia.nch

btl_nyc  So I thought this was Marfan's because the murmur from HOCM is at the left sternal border, but Marfan's is a defect in fibrillin, not in collagen. +3
arcanumm  To help rule out Marfran's, it is stated that there are "no history of major medical illness," which I wouldn't expect them to put if there was a syndrome going on. (they also tend to give body habitus descriptors at least) +
dul071  This isn't HOCM, rather it's simply Mitral stenosis. He has a murmur that radiates at the apex which happens to be the Mitral area. Despite everything his BLOOD PRESSURE AND PULSE are normal. The heart is over working to keep the vitals normal and as a consequence, it is undergoing hypertrophy which dictates the answer +
dna_at  @dull071 I don't think this is MS. That would be 1) diastolic and not systolic, 2) less likely to cause LVH. I believe as others said it is just HOCM leading to MR, which is what we are hearing. MR secondary to HOCM would still increase in intensity with less preload as there would be more LVOT obstruction (thus more regurgitation) +1

 +24  (nbme23#48)
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So for idCdnaa ew anc esu

seoAlz clueo(o)fnzal in(itbih Y54PC0 tohtname)dlyei

octAphmrnie B er(po fioontmar ni ufnlag lcle emm)benra

nafoiuspCgn ntpvere( ckinoglnissr fo beat lasugnc ni clle wlal)

or iayNnts fro oarl ro seagohlpae asesc (rope niofrtmao)

hiTs ouensqit si gynsia tath hse si itkgna an AROL rgdu to treta ndadaci intigias.v

itehcrAmnop si VI

ugnnpaifsoC si soal IV

os w'eer tlef with oezlsa

slezoA biiihtn shsnsiyte fo rertleoosg yb tiibiihnng CYP 504 thta tveoscrn netolraslo ot esgrto.erlo

qball  Nystatin does treat vaginal candidiasis but is TOPICAL. +1
thotcandy  Nystatin is NOT for esophageal candidiasis, Swish and spit, not swallow. +2
staghorn  Me - picks Metronidazole -_- +
alexxxx30  @thotcandy...actually you can swish and swallow nystatin for esophageal infections (per Sketchy micro candida sketch) +3
turtlepenlight  I have seen that on the wards so I hope it works! +
fexx  and my smartass picks amphp B +2
avocadotoast  Please no one give a poor girl with a yeast infection amphoterrible +2

 -1  (nbme23#42)
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shiT eitnatp si peeunivssnor ot nmay .ditacsani eThy tndo fisyecp cwhih oens, but eht osqteuni is blaclayis knagis ichwh cindtiaa si hte togs.sntre haTt dluwo eb PsI,P wchih itiinbh sactrgi H K sPaeAT

yb_26  PPIs are not antacids! +3

 +6  (nbme23#25)
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siufrnsanoT eaoncsrti rae edtadiem yb pTey II hstiitviyenrysep tanrsicoe. sheeT occru ued to rdofperem itasnbodie that idnb ot hte rngeofi iegatnn (AB gpuro no RB)C dan aled ot lyohsmies by NK .sllce hiTs is a morf fo ointyAbd eededntnp elllcrua xociityttc.oy

focus  Exactly! And among the blood transfusion reactions, per FirstAid: allergic/anaphylactic reaction: type 1 (we would see urticaria, wheezing, etc. Seen in IgA deficiency.) febrile nonhemolytic transfusion reaction: type 2 (host antibodies against donor HLA and WBCs) acute hemolytic transfusion reaction: type 2 (ABO blood incompatibility) TRALI: its separate category (donor antibodies against recipient neutrophils and endothelial cells) They specifically told us ABO incompatibility (despite the respiratory symptoms that could indicate TRALI) so we know this is an acute hemolytic transfusion reaction. +2

 +5  (nbme23#41)
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So thsi eutnoisq is bcrgdiisen a ygu nahvig uitcdiyffl lnelaxtery gotantir sih mar ewilh eht moferar is xeedlf. He is lbea ot epuiasnt lwieh sih ram si eteexddn eb(uasce of eth psuanoitr smcule dan ib)e.scp In hte rtortao ffu,c oyln teh ssupitanrfina rrepsomf texrnale ,trntaioo so htat si eth etsb checo.i

Bespci krwso nife rhee

sluiucarSaspb rfeorsmp leraitnn n.tooarit

susSnppariatu esfrporm otnuidcab

isTcper vrdieosp oetinxesn fo a.ermrfo

bigjimbo  technically rotator cuff infraspinatous and teres minor do ER (but teres minor is not a answer choice0 +9

 +1  (nbme22#45)
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Wyh tcna hsti be ilvexs?aat htoB wodul scaeu aeocilmtb lssaiokla wiht e.hpola..myika ?

sup  Laxatives would cause an anion gap metabolic acidosis due to loss of bicarbonate in the stool. You would see hypokalemia though as seen in this question. +1
miriamp3  it took me a lot of time choosing between laxatives and diuretics and at the end I choose diuretics. but I didn't realize that the only thing I had to do was check if were a anion gap or not. +
snripper  Why would laxatives cause anion gap MA? Isn't it similar to diarrhea? +
castlblack  The above comments are incorrect. Diarrhea is a cause of normal-anion-gap metabolic acidosis (D in HARDASS from FA). Laxatives are wrong because they would lower HCO3- but in this scenario it is high. The low K+ and Cl- fits either case though. +4

 +8  (nbme22#40)
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caeeiPlasnrpa is sciblayla enrci"aacPt nems"Eyz ni fycna antsp ENBM rwold

makinallkindzofgainz  "Pancreatic enzymes, also known as pancrelipase and pancreatin, are commercial mixtures of amylase, lipase, and protease. They are used to treat malabsorption syndrome due to certain pancreatic problems. These pancreatic problems may be due to cystic fibrosis, surgical removal of the pancreas, long term pancreatitis, or pancreatic cancer, among others. The preparation is taken by mouth." +

 +22  (nbme22#31)
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In ,ibolgoy eashp anvaoirti is a hmdtoe rfo edliang whit prliyad viraygn vnnenimrstoe wioutht rrigquien odnrma nu.mottia tI sovleniv eht notaviria of pneitro roeseisnx,p elrteyfqnu ni an fonfo- fsnhi,ao thwini nritffdee astpr of a rlcateaib uaoinolpt.p sA shuc hte nppteoyeh can ihctws at rqenseieufc that era uchm hgerhi em(sesimto ;)t1%&g hant ailaclssc otamnuit arse.t Pheas avtniorai bcritoenstu to leirvceun by egarnegtni e.eteyhierongt uoAhgtlh it sah enbe mots lcnyoomm disdeut in the tetxonc of imnmue no,iseav it is rebvdeos in mayn ehtor sarea sa lwle dan si pdylmoee by rvaiuso sptye fo tabceira, iugindlcn Saenalmllo escs.ipe

wrh/enp/ao//dnkwwhmt.i_v:woeiwstiatPsc.iaan

whoissaad  is it the same thing as antigenic variation? +8
dorsomedial_nucleus  No, antigenic variation involves genomic rearrangement Phase variation can be thought of as MORE or LESS of something. An on/off switch. No DNA is being rearranged, just under or overexpressed in response to the environment. +4
makinallkindzofgainz  This isn't in Zanki, Lightyear, or First Aid, and I don't remember ever learning about this in class. Thanks NBME! :D +18
jurrutia  You wouldn't expect the difference in phenotype of a given organism in a given patient to change because of mutations. It has to be something other than mutation. Phase variation is the only option that sounded like non-mutation. +

 +4  (nbme22#35)
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53p is dueattm and ntca bind the TAAT x,ob os htwa sppaehn ot rsratontpinic fo noyriihibt ?rptonise

sI yalscliba awth tsih eoisuntq is tgyrni ot a.sk..

So on ATTA oxb oeprtmor &=t;g eeercaDsd nnigdbi fo RAN rmaeoselyp

link981  You said it, they are "trying" to ask. Should use better grammar. +3
titanesxvi  This is on first aid, and says that the promoter region is where RNApolymerase binds +
nootnootpenguinn  Hakuna NO-TATA box... thank you for this explanation! +

 +3  (nbme22#28)
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sIueesotnsro scseulm era tnvdneerai yb hte luran ern.ve

lFnoxie fo hte ftoo si raentvndie by talibi nerev

leaf_house  Plantarflexion is tibial n. Dorsiflexion is deep peronial n. +5

 +5  (nbme22#41)
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haWt espnhpa newh ouy og tino lodc atrwe? You p.ee

How dose ihst hea.pnp

nVcoritonatcssio of vslesse to rpeveers h,eat uspll tawre tnoi uutaasvrcle ude ot derseaedc acdtoshyirt epresusr in vesss.le ulVmoe goes up, AHD soge nw,od PNA soeg up eud to ceiasedrn .elumvo


 +2  (nbme22#1)
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laci:Ce nesodt meak essn,e it smcoe out fo eth roto of teh taora dan ndse ly.titnasn sahtT not tnigget gcthua up ni the llsuovuv lon.ae

h/retgiftL lc:cio thsat lal IAM srh,acnbe htsta vndeonvuil ni the .tnusaiito

mbiUli:cla thta iggettn culdedco is ioicghploys efrat tih.rb

aWsth letf si MA:S chhiw sgeo higtr aevob hte oud,mednu os i ouldw giiaenm a lunoeadd uvollvsu loduw evovnil eht AMS alyise.

yourswoliness  right colic comes off the SMA +

 +1  (nbme22#8)
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sIt a iue,tirdc os eulvom is ncreside.a

OC3H is ircdeanse eeacusb imtcadolzeeaa dsceuer inatrpobrseo fo HO.C3

Hp is einca,dres aeucsbe C3H-O si a awek ,seba so it uscsk pu aysrt ohedygnr snio ni eht u.einr


 +6  (nbme22#49)
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"PTPM ho-(e-yn2,m1y-l1p,eii3yatdnret)pr6dhr,h4t-eyl- si a uogrdpr to eht irtxeouonn M+,PP cihwh cseasu ameetpnnr spmotmys of nsnoikasPr' dseeias yb stdginyoer idnmcerpaoig resunon in hte tsubanasti igrna fo het irna.b tI has eenb duse ot dtyus siasdee emosld in usvraio amanil .ei"studs kiWi

ilikecheese  pg 508 FA 2019 +14
sbryant6  I thought this was testing "lead pipe rigidity" aka Neuroleptic Malignant Syndrome and its connection to dopamine. Had no clue what MPTP was and got it right still. Probably wrong train of thought though. +

 +9  (nbme22#31)
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htaW od yuo ues to ttrae ictaHep ypplnhteoacE?ah tlaLou.sce tWah eods atth d,o it csiieaifd HN3 in hte IG tctar otni N+4H dan esopotrm osls fo hte notornisuge opurcdst atht eucas plcp.aneeytohah ihTs si who uoy meeebmrr hsit .soepcsr

carmustine  FA 2019 pg 385 "Triggers --> increased NH3 production & absorption (due to GI bleed, constipation, infection)." +4
drzed  To add, you can also use rifaximin which will act as a antibiotic decreasing the production of NH3 from gut flora. Same concept. +3
nevergoingtopost  Lactulose is the correct treatment for hepatic encephalopathy, but it actually acidifies the GI tract (colonic metabolism of lactose → lactate). This favors the NH3 form and decreases NH4+. NH3 is then additionally pulled from the blood into the gut. +

 +12  (nbme22#9)
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eraA C si hreew hte pag cnuojnsit tbeenwe raacdic cmosytye ear. paG tucsnnoJi rea ondfu no het asmlap aermenmb of teh caacrid comyety.

hTe tuisoeqn si laalcbsiy skniag rhwee the apsmal nameberm si ihtw a ubnhc of ciemobh muumobojbm ouy ntod aevh ot urannst.ded


 +5  (nbme21#38)
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The etnpiat ahs pretNnciuoe .veefr FCSG lliw trrseeo hsi eipsluhotn.r

yotsubato  His RBC and platelets are low, but at acceptable levels for someone undergoing chemotherapy. +16

 +15  (nbme21#18)
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Wlel htast a ayller dceru ayw to ncrsee ofr p..esidr.ones

champagnesupernova3  There's really no other way to say it without using euphemisms +2
drdoom  You can’t rule out suicidal thoughts via inference. +
drdoom  LAWYER: Did you ask the patient if she was suicidal? DOCTOR: Well, um, no, not exactly — but, I mean, she seemed okay .. +
drdoom  LAWYER: So, a patient walks into your office, you suspect post partum depression — a diagnosis with known suicide risk — and you didn't ask if she was suicidal? +
drdoom  DOCTOR: gulp +

 +3  (nbme21#33)
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yhW is shi dioibL anor?lm tI's totlayl cdptxeee that eh may heav eercudd ldioib rfeta his ifew ddie 2 eaysr ago from smeo lierhobr epnogolrd snsll.ie

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) +

 +0  (nbme21#39)
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yhW si this TNO cihroa?cdn herseT hitgnno rehe atht relsu ti otu.

drachenx  Chancroid is described as an ulcer.. whilst in this question they mentioned "vesicles". Pretty much only herpes is vesicular +6
whoissaad  They mentioned ulcers too. I chose chancroid as well, couldn't find a clue to rule it out. Also thought "discharge" was pointing you towards a bacterial infection. But guess I'm wrong :) +
emmy2k21  I think NBME/USMLE writers make the assumption the patient is in America unless specified otherwise. Chancroid is not common in the US. If the question stem mentions a developing country, then chancroid can make your differential list. +1
selectuw  for chancroid, there may be a mention of inguinal lymphadenopathy +2
samsam3711  Also with chancroid questions they want you to differentiate it between chancroid and syphilis, (eg. Painful vs. painless) and is usually described as a much larger ulcer that is painful (not vesicular as in this question) +
suckitnbme  Also believe that chancroid does not presents with systemic symptoms like in this vignette. +

 +3  (nbme21#35)
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tiullhBs etzrmioianmo .etinsoqu ouY have ot kown atth teh lnigse ITNR htta eassuc pitenactrais is ons.indidae

gaeP 302 92FA10

rsp  Aren't 85% of these questions memorization questions. How many do you really review later and say, I didn't know that concept? My reviews are always "oh, that is the name of that thing they were trying to get at." +2

 -17  (nbme21#14)
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She has adnreBr eorSuli ieDsaes agpe 149 of srtif ida 9021

sympathetikey  That's a genetic deficiency of GP1b -- not antibody related +8
alexandramda  In Berard Soulierd you have a Defect in adhesion. decreases GpIb and decreased platelet-to-vWF adhesion. Labs: abnormal ristocetin test, large platelets. +

 +8  (nbme21#25)
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Tshi tioesqun is .ipdtsu Wtrea akenti rof a htyehla idviudailn si 20. L a ay.d


 +5  (nbme20#14)
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sTih sunqotei is biltu.hls heT woamn uodlw most ilyekl be civeaatcnd to rtpSe o,epumn cleilspyae fi ehs dah a t.peeosmcnly

E iocl is aosl na sadtlueeapcn eurmitabc ttha caesus ,eoipmunan os atth si oerm lyekil 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

 +1  (nbme20#1)
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apnics"yihs dhuols aslwya unagrceoe leahyth aniai-mnrrdoug unoomi.mniatc"c

osAl royeu' gogin ot od meos srusieo gthins to ruce tshi gil'sr se,aesid gleadni pu ot p.tiauntoma Yuo acnt eidh hatt rmfo ehr.

djjix  Non sense ... you can hide the amputation from her +18
charcot_bouchard  Just show her one leg twice. +4
pg32  I picked "request that an oncologist..." because I figured it would be better to have someone with more knowledge of next steps and prognosis discuss the disease with the family as compared to someone working in the ED... why is that wrong? +2
ibestalkinyo  @pg32: Referring to another physician is almost never an answer for NBME/USMLE questions. Plus, I feel like this would be hiding the patient's problem from her and the patient's parents. +5
dunkdum  I think the reason that you requesting the oncologist isnt the most correct answer here is because... even if more tests needed to be done... you would still discuss with your patient about that fact and say "Hey these results came back suggesting that you might have this disease, we will need to do more testing to make sure we can get it taken care of if you in fact have this disease." and you'd probably do that before you go and get the oncologist. +4
peteandplop  @pg32 I was kind of with you, but I went with the correct answer because it says STRONGLY suggestive. If you're giving me a powerful word to really emphasize this is osteosarcoma, there's no need to delay passing that information to patient, and in this case of a minor, her parents. +1

 +2  (nbme20#7)
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It ntca be cetliaBra absssec aorNicd)a( aeceusb sesh nakgti TMP SXM.

tI cnta eb xo,ot uecseab ehs has one noilse and is oasl tanikg PMT XSM hihwc lhosdu rmeipvo erh ysmom.pts

loGilomtbsaa is a desasie of ldero dilsidauinv

titeataMcs aeidess thta tsme ot eht rabin si ieynllku ta hits ega.

CNS plomaymh si omcnmo in IVH ISDA ,apnttise os tath is teh sotm yillke iec.hoc

mrglass  She's not taking TMP/SMX though. I would pick lymphoma over abscess mainly because .5cm growth in 2 weeks is incredibly rapid, which is classic for diffuse B-cell lymphoma, which is what tends to be in the CNS. Also there was no evidence of a classic source of brain abscess like mastoiditis. +19

 +4  (nbme20#21)
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"Do on "rmah

gSivatnr hte bbya ro nihthlwigod odfo si gidon .amhr tA htis nopit yuo vpoired plltaeiaiv rcae litun hte hetda fo eth yab.b fI het trnsaep edcdie to l"upl teh "pglu hnte htey acn od t,i tub as eth rtoodc attsh tno royu .ceohic

cry2mucheveryday  Why not 'give foods according to normal caloric requirement'? +7
hpsbwz  @cry2mucheveryday because feeding to the caloric may be too much or too little for this baby. considering the baby's crying only resolves with food, if you've already reached the limit, are you just not going to feed the baby? that's how i thought of it. "maintain comfort" is the key phrase. +4

 +21  (nbme20#42)
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ifdiB tcdoair lpssue rae snee in oAcitr snsisote ro rttggaoriiune

dartCio tiBru si arhde hitw leoerhastsrcosi of mmocon taciord earytr

owSl nsiigr eedrsdcae eulovm ctarodi elpus is ccirtiacteahsr of ictrao ossnset.i

oaCnnn avwes aer nsee ni oepetclm VA ,klcob sa igrth ivcertlne nda itara cactonrt n.lntiepneddey

chextra  I mis-remembered normal JVP as 8-12. Therefore, I picked "Slow-rising, decreased-volume carotid pulse". Is there a reason why this is NOT a result of HF, or is it simply not the best (which I agree is JVD)? +1
len49  For those wondering normal JVP is 6-8 mmHg +3
fatboyslim  @chextra I think the reason why it's NOT slow-rising decreased-volume carotid pulse (sign of aortic stenosis) is because the patient had a h/o prolonged substernal chest pain 5 days ago. I think he had an MI and is now presenting w/ heart failure. +

 +2  (nbme19#27)
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ahtW swa sigunfocn ofr me in iths uoqsinte swa ahtt eh hsa an eucat .eetspiortann aTht nidtd ekam eesns to me... eH vlied 74 ryase hwti nreal yarrte osesnist nda now hsa trneohipsyen secaube of ?ti!





Subcomments ...

submitted by russnels(13),

Anybody have any good insights as to what is going on here? Does surgery somehow cause hypokalemia? Or does this have to do with digoxin toxicity? I'm not sure how surgery fits in. Thanks in advance!

misscorona  Looking at UpToDate, hypokalemia is listed as one of few postoperative electrolyte abnormalities. Surgical stress releases aldosterone which leads to hypokalemia. Hypokalemia is a known cause of premature ventricular contractions. Digoxin toxicity can cause premature ventricular contractions but it seems like this patient was on these medications prior to surgery and this may be less likely contributor. Side note, digoxin can lead to hyperkalemia. +2  
yotsubato  Ah so it is a BS question.... Ugh. +2  
krewfoo99  I think surgery/stress will lead to increase in cortisol which acts like aldosterone to cause hypokalemia leading to premature ventricular contractions +  


submitted by yotsubato(968),
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olCo nteraoh iuetonqs ktena fmro eth itls of gthsin tno ni FA

charcot_bouchard  Actually it is in FA. FA 19 Page 100 - Antigen loaded onto MHC1 in RER after delivery via TAP transporter.... Remember FA is that friend who always say I told you so. +18  
yotsubato  But not in this context +5  


submitted by mousie(210),
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is htis sbcaueut srddcetoanii ecodasatsi rvopteiemreoabMrfni-la G?N

jus2234  The question describes how he had a strep infection 15 days ago, and now this is poststreptococcal glomeruloneprhitis, which can also be described as proliferative glomerulonephritis +9  
seagull  The question would be too fair if it just said PSGN. Instead we need to smell our own farts first. +64  
yotsubato  And they used terminology NOT found in FA +5  
water  who said they were limited to FA? +2  
nbmehelp  FA uses the common nomenclature and the fact most of our other resources use the same nomenclature for this, I think we can agree that is is the accepted terms. If they're gonna decide not to use the nomenclature that most medical students are taught then they should provide their own study materials at that point for us to use. The test shouldn't be this convoluted for no reason. +6  
alimd  Ok. They can use terminology whatever they want. But BUN-CR>20 is CLEARLY prerenal right? +  


submitted by mcl(579),
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onusB vcrdeaa dmgaari, dik yhw hsit asw no .r..es.i.?n....p.te.t

drdoom  bonus cadaver diagram via @mcl +  
yotsubato  nurses +4  
faus305  Cause it's cute unlike the monstrosities they always put on the NBMEs +  


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Why duwlo ti otn be aamine of iocrnch aeseisd ithw deaerdesc resum rnrferatsni o?nctnionecatr

lispectedwumbologist  Nevermind I'm stupid as fuck I see my mistake +1  
drdoom  be kind to yourself, doc! (it's a long road we're on!) +20  
step1forthewin  Hi, can someone explain the blood smear? isn't it supposed to show hypersegmented neutrophils if it was B12 deficiency? +1  
loftybirdman  I think the blood smear is showing a lone lymphocyte, which should be the same size as a normal RBC. You can see the RBCs in this smear are bigger than that ->macrocytic ->B12 deficiency +22  
seagull  maybe i'm new to the game. but isn't the answer folate deficiency and not B12? Also, i though it was anemia of chronic disease as well. +  
vshummy  Lispectedwumbologist, please explain your mistake? Lol because that seems like a respectible answer to me... +9  
gonyyong  It's a B12 deficiency Ileum is where B12 is reabsorbed, folate is jejunum The blood smear is showing enlarged RBCs Methionine synthase does this conversion, using cofactor B12 +  
uslme123  Anemia of chronic disease is a microcytic anemia -- I believe this is why they put a lymphocyte on the side -- so we could see that it was a macrocytic anemia. +2  
yotsubato  Thanks NBME, that really helped me.... +1  
keshvi  the question was relatively easy, but the picture was so misguiding i felt! i thought it looked like microcytic RBCs. I guess the key is, that they clearly mentioned distal ileum. and that is THE site for B12 absorption. +6  
sahusema  I didn't even register that was a lymphocyte. I thought I was seeing target cells so I was confused AF +  
drschmoctor  Leave it to NBME to find the palest macrocytes on the planet. +4  


submitted by medstruggle(12),
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yWh si hte ewnras laitraongnu“ ”eitu?ss I htugoht trefa 14 sady ouy ahve a uyllf emfodr s.acr

colonelred_  If you go back and look at the image you can see that it was highly vascular which is characteristic of granulation tissue. Scar tissue formation will be closer to 1 month, plus you will see lots of fibrosis on histology. +13  
sympathetikey  It's a bit misleading, for me, since you do see fibrosis intermixed with the granulation tissue, but granulation tissue was a better answer. +2  
haliburton  According to FA 2017: 3-14d: Macrophages, then granulation tissue at margins. 2wk to several months: Contracted scar complete. Dressler syndrome, HF, arrhythmias, true ventricular aneurysm (risk of mural thrombus). i'm getting pretty frustrated with NBME contradictions to FA, and FA omissions of content. this stuff is hard enough to get straight as it is. +1  
yotsubato  Thats cause the NBME exam writers read FA, then make questions not fit in with FA +6  
trichotillomaniac  This fits the timeline laid out in Pathoma! 1-3 wks = granulation tissue with plump fibroblasts, collagen, and blood vessels +10  
alimd  never look at the image in the beginning. They dont want you to success. Most of the time images are made to ditract +1  


submitted by neonem(550),
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oltnplbeeCnioree nagel ssma = eVblaritus csananwmho KA(A tosuccia am.onu)re devDier form acnShwn elcl,s ciwhh rae of laenru srcte .inigor

yotsubato  Ugh. Of course they dont put schwann cells as a choice. So I pick oligodendrocytes like a dumbass +32  
subclaviansteele  Same^ +1  
madojo  Schwann cells = PNS Oligodendrocytes = CNS +3  
suckitnbme  NBME loves their neural crest cells +4  
wrongcareer69  How much do they pay these testwriters anyway? I can use a thesaurus too +2  
osteopathnproud  @suckitnbme they do love their neural crest cells, I have chosen neural crest cells for every single answer choice I see it in and I believe I gotten 90% of them correct, if something doesn't click or you don't know, I would keep neural crest cells as a very possible answer lol +  
faus305  AMERICA EXPLAIN +  


submitted by lsmarshall(393),
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I tothuhg iths aws a ctrik osnquiet nseci sink srceanc rea eth osmt oomcnm ytpe of acrncse leav.lro uBt ltacyalu namog VHI aipents,t eIlerdta-HV anrcesc ear ucmh meor nocomm athn tednlnVeao-rHI- ccneasr even( kins n.rcec)sa dnB-ieVEcdu prriaym NSC opymhmla si eth lnoy oniopt tath is gdsi-IAifnneD /nenea.slrcislc

medskool123  why not hep B? i guess another whats the better answer ones... Just rem reading that it was more common with aids pts.. anyone have an idea about this? +1  
haliburton  Yes, I think CNS lymphoma as an AIDS defining illness wins the day. My thought was since SHE has AIDS it is most likely from IVDA, which has a high risk of HBV that could go undiagnosed for a long time. at 32, that might not be long enough to have HBV and get HCC (but with no immune system...?) +3  
yotsubato  God damn this is such BULLSHIT... +13  
trichotillomaniac  Why you gotta do me dirty like this NBME +2  
sars  My thought process, usually wrong all the time, was that HBV (IVDU) can occur to anyone. Acute hepatitis to Chronic occurs when HBV incorporates its DNA into host and releases mutagenic proteins. This is regardless of immunosuppresion. Primary CNS Lymphoma reappears primarily when you are immunosuppressed (organ transplant, immunodeficiency, HIV/AIDS). +  
syoung07  Hep C is far more likely to become HCC than hep B +1  


submitted by seagull(1404),
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-A arryimp trmoo xtecor = onwrg sdei of bydo (fitdeci of NUM on fetl isde dyob)

B - uasTmlha = ysnseor omnrinafiot utcndio - oromt fieitscd leiuknly ot ireiongat ofrm erhe

C - nosP - sNC ,67,,,58 ylikel rstelu ni kel"cod in nmdyers"o ro cempleto slso fo oomrt octniufn on rihtg side + caflai aee.sturf

D. emVris - eatnlrc yobd oroiinntacdo. aegamD elsrsut ni aaxtai

oNt epmolect ubt eaymb f.ple.hul

yotsubato  C - Pons - CNs 8,7,6,5, likely result in "locked in syndrome" or complete loss of motor function on LEFT side + RIGHT sided facial features. Decussation occurs in medulla +2  
kard  Sorry if im mistaken, Isnt A) Somatosensory? +2  
krewfoo99  Yes i think A should be somatosensory. Primary motor cortex would be present in the precentral gyrus +  
drpatinoire  A is primary motor. A and the gyrus at right side of A compose the paracentral lobule. +  


submitted by lsmarshall(393),
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iovntpbyenraS si het trtage fo mitnspsneaato sa(tteun xtn)i;o eusmcl sssapm are t.rcihsrciaatce lynO orhte saerwn yuo hgmti iecodsnr si eestccyeslAlornaihet ecisn he si a framre and obszzrudw etofn rcrya su ot teh ipdmores .a.dl.n tbu mmssytop fo a oncehiicrgl tmrso era bet.asn

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +41  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +42  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +34  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +2  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  


submitted by lsmarshall(393),
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nrvinSpyobaet si the tagret of seaatonnpimst unt(etsa tx)i;no smleuc massps rea iiah.rtcstacecr lOny eothr werans ouy mihtg ersodcin si slcyhorceatsteenilAe sienc he si a armref nad szwbodurz often yarcr su to the osrmdepi lan...d utb tsmsyopm fo a oniehicrgcl tsrom rea abste.n

vshummy  Synaptobrevin is a SNARE protein. Why they couldn’t just give us SNARE I’ll never know. +41  
yotsubato  Cause they're dicks, and they watched sketchy to make sure our buzzwords were removed from the exam +42  
yotsubato  Oh and they read FA and did UW to make sure its not in there either +34  
soph  This toxin binds to the presynaptic membrane of the neuromuscular junction and is internalized and transported retroaxonally to the spinal cord. Enzymatically, tetanus toxin is a zinc metalloprotease that cleaves the protein synaptobrevin, an integral neurovesicle protein involved in membrane fusion. Without membrane fusion, the release of inhibitory neurotransmitters glycine and GABA is blocked. -rx questions! +6  
qfever  So out of curiosity I checked out B) N-Acetylneuraminic acid It's sialic acid typical NBME +2  
alexxxx30  shocked they haven't started calling a "farmworker" a "drudge" <-- word I pulled from thesaurus. +2  
snripper  "You shouldn't memorize buzzwords. You gotta learn how to think." Lemme pick another random ass word that doesn't have anything to do with critical thinking skills and use it instead. +5  
mw126  Just as an FYI, there are multiple "SNARE" Proteins. Syntaxin, SNAP 25, Synaptobrevin (VAMP). From google it looks like Tetanospasmin cleaves Synaptobrevin (VAMP). Botulism toxin has multiple serotypes that target any of the SNARE proteins. +2  
wrongcareer69  Here's one fact I won't forget: Step 1 testwriters are incels +2  
baja_blast  FML +  
j44n  its not an ACH-E inhib because he doesnt have dumbell signs +  


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hnkTa oyu NMBE rof hte ihgh qaulyit csuepi.tr It eskam etseh xemas sserst fere dna oeaybjlen.

sympathetikey  Feels bad man. +3  
zoggybiscuits  Those Sclera sure look blue. wow. +18  
yotsubato  the same girl shows up on so many NBME exams its not even funny. Its just like that poor kidney that's cut in half that shows up in all kidney questions. +12  
aneurysmclip  I turned my brightness up and down 2 times to make sure it wasn't my brightness messing with the sclera. I'm declaring it, NBME stands for "Naturally Bad at Making Exams" . +6  
peqmd  $60 a pop and no competitors...That's what happen when there's a monopoly. +4  
peqmd  Actually they used their best software to generate images. You might have heard it before, it's called MS Paint. Quite legendary. +6  
feochromocytoma  It feels like they cranked up the contrast and saturation on a normal eye to make it look "blue"... +5  
rockodude  everyone hates on nbme, but they're showing you a picture zoomed in of her eyes and she has a history of multiple fractures/bad wound healing at the age of 4, I feel like OI should at least be a consideration based on the overall clinical picture +1  
feochromocytoma  Yeah I got it right, it's just funny that they don't use higher quality pictures for the exam +1  
djeffs1  that is clearly a malar rash... oh wait nvm just pixellation +2  


submitted by colonelred_(100),
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oLeodk ti pu nda fnudo ttah euescab y’eour ni a speinu ptiisoon ofr a ognl tiem ueo’ry gogni to haev ensearcid eovsun ntrreu cwhhi ldase to naecdirse OC. shTi inaevgelty askecdefb no SRA,A lgneiad to sedrcedea aoltesroen.d As a ,surelt uyro’e ngoig ot eavh ineeradcs sieiusrd ihcwh esald ot ddreeesca obdol and mlasap olum.ev

medstruggle  Doesn’t supine position compress IVC leading to decreased venous return? (This is the pathophys of supine hypotension syndrome.) There was a UWorld questions about this ... +4  
tea-cats-biscuits  @medstruggle *Supine position* decreases blood pooling in the legs and decreases the effect of gravity. *Supine hypotension syndrome*, on the other hand, seems specific to a pregnant female, since the gravid uterus will compress the IVC; in an average pt, there wouldn’t be the same postural compression. +7  
welpdedelp  this was the exact same reasoning I used, but I thought the RAAS would inactivate which would lead to less aldosterone and less sodium retention +3  
yotsubato  You gotta be preggers to compress your IVC +5  
nwinkelmann  Could you also think of it in a purely "rest/digest" vs "fight/fright/flight" response, i.e. you're PNS is active, so your HR and subsequently your CO is less? But the explanation given above does make sense. Also because I think just saying someone is one bed rest leaves a lot up for interpretation, maybe not with this patient because his pelvis is broken, but lots of people on bed rest aren't lying flat.... ? +1  
urachus  wouldnt low aldosterone cause low plasma sodium? choice B +5  
kpjk  could it be that, while low aldosterone levels decrease plasma sodium levels- there is also decrease in blood volume(plasma),so there wont be a decrease in the "concentration" of sodium +4  
almondbreeze  FA 2019 pg 306 on Lt heart failure induced orthopnea - Shortness of breath when supine: increased venous return from redistribution of blood +  
almondbreeze  if there was no HF, it would lead to increased CO --> decreased aldosterone +  


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nCa aydnyob nialxpe shit neo? I put etaeeprd sstet abeucse I uemssad na reyoa-8ld3- nawmo si an uuluasn ahrepcimogd rof .hslypiis

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +5  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +4  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +12  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +10  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +13  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  
imtiredofstudying  the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +  


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anC nyoaydb xlpaien hsti ?one I tpu aeepertd sstte asecbeu I esamsud an -8-dyorela3 mwano si na lansuuu caohmiegpdr for yilhs.spi

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +5  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +4  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +12  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +10  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +13  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  
imtiredofstudying  the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +  


submitted by mousie(210),
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A eTne htiw toeincinj of hobt aniuvtnccjo = wede locdu olas be iusganb troeh gruds s I 12 asyer dol nda oufr ontmsh jtus too dol and too onlg of a meti ofr it ot be g?iemtiop I rdrawnoe it dwno ot eshte wto nda edesgus u...tb I 'tnsaw rseu I dlcou inmtaiele .it

medskool123  I picked impetigo because of the gold stippling... I guess I took that as honey crusted lesions. F*ck NBME. +6  
yotsubato  Huffing gold spray paint. A la the chrome huffers in Mad Max +7  
subclaviansteele  LOL I think that might be what they were going for here. Gold spray paint. +3  
et-tu-bromocriptine  Anyone know what may be causing his weight loss and unwillingness to eat? I thought too much into it and put "mercury poisoning", since I thought the heavy metal's abdominal symptoms may have caused him to not want to eat. ¯_(ツ)_/¯ +3  
covid2019  I'm not sure about the pathophysiology there... But I do know that inhalants are popular in places where there's extreme poverty. I spent some time abroad, and one of the patients was using inhalants to take the edge off the hunger, so that she could spend her money on food for her kids instead. She also worked on the streets so I guess it also made it easier to, you know... +2  


submitted by yotsubato(968),
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Why is the iteptan ton in .ianp I dwotnul exctep Icardneetarc ranhie to preetsn iwth erzo naip, tub 1 ekwe fo siioopctnant dan lesw.ngil

yotsubato  Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Like really? Why is he not in pain? +1  
medschul  I thought that inguinal hernias were reducible? +  
fahmed14  could be a femoral hernia as they are more likely to cause incarceration. They do, however, present more often in females. (FA 2019- 364) +1  
wowo  incarcerated, not strangulated, thus no pain as there's no serious tissue damage/ischemia. Incarcerated hernias may progress to strangulated in which case he would have pain Under section, "complications" https://www.amboss.com/us/knowledge/Inguinal_hernia +5  


submitted by majic(7),
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HTE MOTS COMNMO reout fo Txoo rsstisomnnia in dsuatl in het UAS is iotsnnegi fo onedrdcuoke orp.k Even fi cat rtleit si an ito,pon ddeurocoekn pkor is lilst orem .moconm

yotsubato  Also another fun fact. Most people in France are infected by Toxo (like 80%) because of how they eat meat. (Very rare) +2  
madojo  To add on might be TMI but most people have Toxo but are asymptomatic because its in its latent form as a pseudocyst and its not untill you are immunocompromised that it strikes +  
suckitnbme  This patient also probably got toxo in Brazil +  
luciana  JFYI people in Brazil love to eat rare meat at barbecues +  


submitted by wired-in(67),
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naniMtcenea dose lafmuro is C(ss × lC × au)t ÷ F

erhew Css is tadtesea-yst rtgtea mlapsa o.ccn of ,rgdu Cl is calcaneer, uat is gdoeas traevnil pm&;a F is ibatav.iioalliyb

reeihtN odgeas rialvnte nro oliyibblaviaiat is ievgn, os ngiirong othes pm&a; lgugpgni ni hte rnsmbue le(ufcra ot ocetvrn tunsi to ad)ky:mg/g/

2 (=1 /guLm × 1 /g0m010 )gu × .0(09 /Lghkr/ × 0010 /m1L L × 42 /r1h dy)a
= 259.2 /dygkagm/

.chhi..w ns'ti nay of the aersnw eshicoc disle.t hTey sutm have ndroedu .009 rh//Lkg to .10 hL,/g/kr adn digon so eisgv xyeatlc .828 kma/ygdg/ cic(ohe )C

lispectedwumbologist  That's so infuriating I stared at this question for 20 minutes thinking I did something wrong +69  
hyoid  ^^^^^ +11  
seagull  lol..my math never worked either. I also just chose the closest number. also, screw this question author for doing that. +9  
praderwilli  Big mad +9  
ht3  this is why you never waste 7 minutes on a question.... because of shit like this +8  
yotsubato  Why the FUCK did they not just give us a clearance of 0.1 if they're going to fuckin round it anyways... +18  
bigjimbo  JOKES +1  
cr  in ur maths, why did u put 24h/1day and not 1day/24h? if the given Cl was 0.09L/hr/kg. I know it just is a math question, but i´d appreciate if someone could explain it. +1  
d_holles  LMAO games NBME plays +2  
hyperfukus  magic math!!!!! how TF r we supposed to know when they round and when they don't like wtf im so pissed someone please tell me step isn't like this...with such precise decimal answers and a calculator fxn you would assume they wanted an actual answer! +1  
jean_young2019  OMG, I've got the 25.92 mg/kg/day, which isn't any of the answer choices listed. So I chose the D 51.8, because 51.8 is double of 25.9......I thought I must have make a mistake during the calculation ...... +6  
atbangura  They purposely did that so if you made a mistake with your conversion like I did, you might end up with 2.5 which was one of the answer choices. SMH +3  
titanesxvi  I did well, but I thought that my mistake was something to do with the conversion and end up choosing 2.5 because it is similar to 25.92 +2  
makinallkindzofgainz  The fact that we pay these people 60 dollars a pop for poorly formatted and written exams boggles my mind, and yet here I am, about to buy Form 24 +15  
qball  Me after plugging in the right numbers and not rounding down : https://i.kym-cdn.com/entries/icons/original/000/028/539/DyqSKoaX4AATc2G.jpg +1  
frustratedllama  Not only do you feel like you're doing sth wrong but then that feeling stays for other questions. sucks so baad +  
fexx  'here.. take 50mg of vyvanse.. I just rounded it up from 30.. dw you'll be fine' (totally doing this with my patients 8-)) +1  
cbreland  I was so close to picking 2.5 because I thought I did a conversion error. 5 minutes later and still didn't feel comfortable picking 28.8😡 +  


submitted by sympathetikey(1252),
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oerc:Su sdn.iiiwteh/g/enteawlpik.io/ykr:pMi/

ln"ymei eepssd hte irsosasnmint fo lcilecreat ipsesmul ecalld tocani toapsnetil oangl eltendyami sxnao yb sgiuniltan het xona nad gdrneciu oanxal remeabnm acaieacptnc"

littletreetrunk  I think this makes total sense, but how does it not ALSO stop fast axonal transport? +3  
laminin  axonal transport is transport of organelles bidirectionally along the axon in the cytoplasm since myelin is on the outside of the axon demyelination doesn't affect this process. source: https://en.wikipedia.org/wiki/Axonal_transport "Axonal transport, also called axoplasmic transport or axoplasmic flow, is a cellular process responsible for movement of mitochondria, lipids, synaptic vesicles, proteins, and other cell parts to and from a neuron's cell body, through the cytoplasm of its axon." +3  
yotsubato  axonal transport is mediated by kinesin and dynein. Microtubule toxins like vincristine block these +3  
drdoom  @littletreetrunk "axonal transport" is movement of bulk goods via microtubules (which run from soma to terminus); ions, on the other hand, move in an "electrical wave" that we call an action potential! no axonal (microtubular) transport required! in other words, de-myelination will have no effect on the transport of bulk goods; but it will really mess up how fast "electrical waves" traverse the neuron! +  


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naC ennoya lpexnia ohw 0cm1 H20 eoivpsit EPEP sadle to eakP istraoyrnpI PA, dEn aliTd A,P Pkae sairIynprot Ppi and dnE adilT Ppi all ibgne p?vtiioes

tea-cats-biscuits  In PEEP, bc of how mechanical ventilation works, all the inspiration part of breathing is done by the machine actively pushing air into the lungs. As a result, there is no negative pressures in the system compared to the normal lung which needs the negative inter-pleural pressure to draw air in. +27  
yotsubato  " As a result, there is no negative pressures in the system compared to the normal lung which needs the negative inter-pleural pressure to draw air in. " Thats totally what threw me off. TIL +  


submitted by welpdedelp(216),
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3*0 .105. iTkhn atobu ti, etrhe si x oflw htiw na xyeong oectnarocnitn of -soy- to nifd out eht veidelyr you jsut ptuilmyl meht er.thotge

yotsubato  One of those questions too simple to believe its actually the right answer +27  
mimi21  Right, I was like this is too simple lol ! im not sure if this is also a good tip but I tend to look at the units they are asking for and double check my math to make sure I end up with them. +7  
osgood-schlatter  what equation is it exactly? +  
arcanumm  Literally did not even conceptualize this question, just looked at the units. +4  


submitted by sakbarh(5),
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hSe sah mayn oacrlvcdsiaura rski soatrfc dna eiklly fsereduf a ostrek of the laaisrb ryerat ganiscu coeldk ni n.dsyomer rccgAdnio to AF hist acn csaeu a nilose ta eht op,sn r,eulaldm or wrole dmbniira -- vrwehoe latyicalmnoa eth rasliab yaretr srun tgirh on pot of teh osnp so mirioxpyt otms lelyki kemas it het higtr rse.nwa

mousie  The Boards and Beyond video of SC strokes was really helpful at explaining this if you are a video kind of person! +1  
yotsubato  What pushed me away from pons was "dysarthric speech" which implied she still could speak to some degree.... which made me pick medulla. +3  
mimi21  I think FA may be misleading. Primarily it will effect the Pons because that is where the majority of the Basilar Artery is located. and I guess it could effect the other locations? but everywhere I have looked Locked-in syndrome is an issue with the Pons. But someone please continue to clarify, cause I was a bit tripped up at first with this question +  
cbrodo  Although FA says it can be pons, medulla, or lower midbrain, "locked-in" syndrome generally arises from BL pons lesions. Another way you can rule out medulla and midbrain in this question is the ocular movement findings. Since the patient has impaired horizontal gaze BL, you can conclude that the Abducens nuclei are involved on both sides. The abducens nuclei are located in the pons. +40  
gh889  USMLE secrets also states that it is most commonly in the pons Bates states that locked-in syndrome preserves consciousness but these patients have limited speaking ability +  


submitted by mousie(210),
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Why on atgn?swei I mean I etg cysstaE is broybpal hte drug fo iccohe roebef na all tnhgi aendc rpyat l()ol btu ot'nd aredsdntun why heter wloud be olcd xmeitreetsi dna no istwnage hnew si FA ti says rpetaihrymeh adn ??o?drah?b

sympathetikey  FA says, "euphoria, disinhibition, hyperactivity, distorted sensory and time perception, bruxism. Lifethreatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin syndrome." So I think they wanted you to see Sinus Tachy and jump for MDMA. Idk why Ketamine couldn't also potentially be correct though. +11  
amorah  I picked ketamine because it said no diaphoresis. But if you need to find a reason, I guess the half life of ketamine might rule it out. Remember from sketchy, ketamine is used for anaesthesia induction, so probably won't keep the HR and BP high for 8 hrs. In fact, its action is ~10-15 mins-ish iv. +9  
yotsubato  Because the NBME is full of fuckers. The guy is probably dehydrated so he cant sweat anymore? +18  
fulminant_life  you wouldnt see tachycardia with ketamine. It causes cardiovascular depression but honestly i saw " all-night dance party" picked the mdma answer and moved on lol +8  
monkd  Ketamine acts as a sympathomimetic but oh well. NBME hasn't caught on to ketamine as a drug of recreation :) +4  
usmleuser007  Why not LSD? +  
d_holles  @usmleuser007 LSD doesn't cause HTN and ↑ HR. +1  
sbryant6  @fulminant_life FALSE. KETAMINE CAUSES CARDIOVASCULAR STIMULATION. +9  
dashou19  Take a look at why the patient has pale and cold extremities. "Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008716/ +3  
drzed  @sbryant6 you're both saying the same thing. Ketamine has a direct negative inotropic effect on the heart, but it is also a sympathomimetic. You are both correct. +  
paperbackwriter  @drzed Can you please site that? As far as I understand ketamine has a sympathomimetic effect on the CV system --> increased chronotropy and BP. I also don't see how they're saying the same thing. One person said "stimulation" and the other said "depression" +  
nutmeg_liver  People tend to drink a lot of water on MDMA. I just guessed the confusion was a result of hyponatremia (too much free water) but no idea if there's any data saying that people tend to become hyponatremic due to water over-consumption on MDMA lol. +1  
cassdawg  "Despite possessing a direct negative cardiac inotropic effect, ketamine causes dose dependent direct stimulation of the CNS that leads to increased sympathetic nervous system outflow. Consequently, ketamine produces cardiovascular effects that resemble sympathetic nervous system stimulation. Ketamine is associated with increases in systemic and pulmonary blood pressures, heart rate, cardiac output, cardiac work, and myocardial oxygen requirements."(https://www.openanesthesia.org/systemic_effects_of_ketamine/) +  
brise  LSD does cause HTN and tachycardia according to uworld! @d_holles +  


submitted by lfsuarez(141),
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irsFt ehtar dunso S)(1 is eantdeger yb otw aehrt :velvas het limtar vaelv nad itcsdpiru elvv.a ayrelN usumoilsetna olgsnic of etshe vvasle omanlylr rtsagneee a sglnie S1 .dsnou Stiltpgni of eht S1 sunod si hrdae hwen tirlma dan ridutpics slavev olsec at lsitlghy efifnedtr sm,tie htwi lasuuly hte mitrla cigonls freeob tsipricdu

yotsubato  Then why the fuck is it describing a mitral valve sound in the tricuspid area +22  
dr.xx  it's describing a splitting S1 — consisting of mitral and tricuspid valve closure — that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. +30  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +4  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +1  
drzed  It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post) The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound. +9  
alexxxx30  yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation. +10  
jesusisking  Thanks @alexxxx30, you the man! RIP Kobe +  


submitted by sajaqua1(519),
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dltWuno' aotlt VA nloda latboani tersody ot hthymiiutcaytor of the cmeparak?e haTt dolwu mnea ttha bloew het VA done het tryhhm wdoul be edirodvp by a rvancierlut ,ocif nda tseoh uluasly rteeca wedi RQS xmsplceoe.

haliburton  that was my reasoning as well. guess not. +  
yotsubato  Shitty NBME grammar strikes again. +1  
charcot_bouchard  No. No guys. Bundle of his located below AV node and it can generate impulse. it calls junction escape rhythm and narrow complex. Below this is purkinje, bundle branch & ventricular muscle. those are wide complex +13  
abhishek021196  Third-degree (complete) AV block The atria and ventricles beat independently of each other. P waves and QRS complexes not rhythmically associated. Atrial rate > ventricular rate. Usually treated with pacemaker. Can be caused by Lym3 disease +2  


submitted by aladar50(40),
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Fro het EC,G I niilayitl hthugot ti wsa n2d edrege eTpy 1 abueesc ti edemse ttha the RP lrntsivae ewer geinarcnis iuntl a bate wsa p,oeprdd tub if uyo olok ta ti selo,cyl mose fo het P vswae ewer ieddhn ni eht RSQ emelcp.xso fI uoy cineto tht,a tehn uyo acn ees that ehret wree lruegar P aswve nda reularg RQS mpoex,cesl but tereh wsa a tlpeemco iaodtsciison webeetn tmeh hihwc easmn ti aws 3dr grdeee haret bo,klc os hte enrwas was tibaoaln anre hte AV .dnoe

yotsubato  answer was ablation near the AV node. No it wasnt. It was ablation OF THE AV node itself. Which faked me out. +9  
makinallkindzofgainz  The tangent by user "brbwhat" says that there is "pr lengthening progressively" but there is not. This is 3rd degree AV block. The P waves march out consistently at their own rate, and the QRS complexes march out at their own rate. There is complete dissociation between the P waves and QRS complexes. They have no relationship. This is exactly what you would see if you ablated the AV node. The SA node would continue to to create P waves. The bundle of His would continue to generate junctional (normal looking) QRS complexes. +6  


submitted by seagull(1404),
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shTi is a eypt II Ralne Tabluur iAc.iodss yM iMalecd lohoSc erNve thugta thsi to e.m diD yuo asol go to vyretop med ?ochsol m'I ssupdirer eyht eenv evga su ltteoi aerp.p

mousie  haha mine didn't either. But they usually leave out most high yield info so, to be expected I guess. +6  
yotsubato  I didnt have physiology in my medical school. None, zip, zero, none. Nor did I have biochem. They said "you learned all this shit in undergrad, youll memorize it again for step 1 and forget it promptly" and then just moved on. +9  
jcmed  In the Caribbean thats 1 thing we were given... lots and lots of toilet paper +1  


submitted by seagull(1404),
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htaW a lrebietr e.putric hyTe tyhe cvdoree pu atpr of ti iwht seil.n TFW

sympathetikey  Agreed. +10  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +  


submitted by seagull(1404),
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hsiT ttaenpi is ptignrpi allsb. retBet do a grdu enserc wcihh semse boisuvo.

sympathetikey  When the answer is so obvious that you pick a stupid answer instead of it. DOH +37  
jooceman739  Funny thing I noticed is "he is alert and cooperative. He appears to be in pain" So he was so high that he was alert and cooperative during the basal ganglia hemorrhage +5  
yotsubato  @sympathetikey That fucking guy who drinks 2 six packs a day with liver failure got me like that. +1  
yogi  probably the "drug" have to be a stimulant or a hallucinogen which causes HTN & Tachycardia. +2  
charcot_bouchard  Lol. I got the right answer but took long time +  
goodkarmaonly  The patient's B.P. and pulse are raised + Bilateral dilated pupils = Most likely use of a stimulant Thats how I reasoned it anyways +  
llamastep1  Bilateraly messed up pupils = Drugs (most of the time) +  
targetmle  why is there basal ganglia hemorrhage? +  
dul071  Wait! doesn't it take like a week or two to get the results back!?!? i chose to measure catecholamine levels because that may be more timely. but clearly i'm wrong +1  
usmile1  basal ganglia hemorrhage is an intraparenchymal hemorrhage secondary to hypertension. according to FA, this occurs most commonly at the Basal Ganglia (FA19 pg 501) +1  


submitted by sajaqua1(519),
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seceuBa the b'saby htreom has Type 1 ieDsbeta lmlt,uesi it si pusbilale thta ythe hda elvadtee dolob ugleosc lvslee niurdg or hrltyos oefber bh.tri inslunI esod ont rsocs eht cata,pnel btu cegulso e,dso so uinrgd rtihb hte neteaon uwlod veah nebe pycg.mrclheeiy Tsih uwlod dael to eht anatoenl pasecran elsarengi liisn,nu riidgvn eocsugl inot lscel dna gniurtn ndwo elu;isseconggoen htsi is hyw het bbya is yclygecipmho rgtih own.

B) reecaDdse egoynglc tcrtiooneacnn- I dn'to ownk eth eglyocgn nnorcoatntiec derapcmo to na autld npti,ate utb a crdaeese in glncgyoe ontrtncaoecin lduwo catnidei ygcgceensllog/uo eela,sre ihcwh duowl nto eb a ilyomhcpyegc as.tet C) edersDcae lgeognyc ethssyna tiyi-vatc deacredse nycoggle shtasyne ytviiatc nidsitcea ryngee aloics,atmb nad uowld eald to ehihrg muers uosgcle elvls.e D) cardeseeD umesr ininsul ctanenooicr-nt arscedeed mersu inislun lwuod ldae ot igrheh elslev fo glcusoe ni sem.ru )E esenrdcaI rsume lkiinsuin-el gorhtw ocfrt-a GFI seod nto bind raleyn as lewl to insniul rtrcsepoe sa nulnisi ,eosd nad os wodul eahv to eb ni exlytmere ghih iennacnrttcoso to aveh htis ffece.t IFG si scetasidoa whti ocmaist thwogr adn esclum nv.eomeetlpd

yotsubato  His glycogen concentration is high, since he's been hyperglycemic with lots of insulin until birth. +3  
alexb  Also explains why he's 12 pounds. +3  
krewfoo99  Also, think of it like this: Insulin causes hypoglycemia, thus this baby must have increased insulin. It is also an anaobolic hormone which is clear by the babys weight. Insulin increases glycogen synthase activity, and causes an increase in concentrations of glycogen. Decrease in insulin would do exactly the opposite +1  
tyrionwill  fetus of a mom with DM will develop pancreatic beta cell hyperplasia, which leads to insulinemia trying to reduce the blood glucose. after birth, the excessive blood glucose will be automatically withdrawn while the insulin at that moment is still high, which leads to hypoglycemia. +2  


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ailaarM can amrpii ieptcah sugneengcilsoeo nda nca aols eumocns solceug fro ist wno belaiocmt eadsmd.n

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 +  


submitted by seagull(1404),
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yWh is ihts ont SH?U wHo did yuo sygu craahppo hte oetn?uiqs

joonam  I think if this was HUS (d/t a bacterial infection) the leukocyte count would be abnormal (11k<) +  
yotsubato  normochromic normocytic RBC thats why. You would see schistocytes +9  
vulcania  Also for HUS I would expect mention of h/o bloody diarrhea, or at least diarrhea (not URI), and mention of something to do with kidney damage. +  


submitted by medstudied(1),
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Wyh is it znicaymiorht ton xiy?olcdynec oidcArncg to cyehtk,s oyu atetr cmdihaayl htwi cmoasdlry/oiedx oa+.rxtenefci Yuo tetar niiaesres haoronerg thiw oylayxneiiexm+fccicrnzhtotcre.dyiao+n

o​Nt eusr hawt hsit qituneso si itegtns -- is ti tagnwni us ot nkwo atht rnheargoo sah to be eadttre sa l?wle In that ca,es dyxo dlwou wokr for tohb occnrgdia to syktche ... nAy reoth nrsegosnia rce!ppditaea

dr_salface  The patient in the stem is pregnant! The question wants to see if you know that doxy is a teratogen. Tetracyclines in general like to bind to fetal bone/teeth which can impair development. +32  
dr_salface  As a side note, treating chlamydia alone only requires macrolides or doxy. Treating gonorrhea alone only requires ceftriaxone or macrolides. The reason sketchy includes all three is because you usually treat one infection and co-treat the other. +3  
yotsubato  Theres a crow in the chlamydia sketchy. You can use Macrolides, OR Ceftriaxone, OR Doxycycline. Most doctors in real life just give the azithromycin z pack (which kicks ass cause its one drug 5 doses thats it) +3  


submitted by dr.xx(142),
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hTe smto nmocom nda sereve omrf of otaamsoul ointmdan oypsylticc dekiyn diessae PDKA(D) etussrl fmro tmiaotsnu ni PKD,1 geodnnic oy-nt1ipsycl C(.).P1

l/.8nlevt/sh/.paccg:cnrP84in39m4.sCwMipb/wthoi4m.//wt

yotsubato  Here we thank FA for failing us yet again. Giving us PKD1, but not polycystin. I got the question right but I just guessed it because nothing else made sense. +14  
usmleuser007  Autosomal dominant polycystic kidney disease 1) occurs in patients with mutations in the gene (PKD1) encoding polycystin-1 (PC1). 2) PC1 is a complex polytopic membrane protein expressed in cilia that undergoes autoproteolytic cleavage at a G protein–coupled receptor proteolytic site (GPS). 3) A quarter of PKD1 mutations are missense variants, though it is not clear how these mutations promote disease. 4) GPS cleavage is required for PC1 trafficking to cilia. 5) A common feature among a subset of pathogenic missense mutations is a resulting failure of PC1 to traffic to cilia regardless of GPS cleavage. 6) Missense mutation in the gene encoding polycystin-2 (PC2) that prevented this protein from properly trafficking to cilia.  +2  
waterloo  yotsubo - the book is already so thicc. I think you made a great point tho, nothing else made sense. Sometimes you can't know everything on the test, but you can still play the game. +1  


submitted by lnsetick(90),
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owH are uyo bela ot llet tath teh CT sicle is otn ta eht llvee fo mdunuoe?d

zelderonmorningstar  I think the small intestine narrows as you go along, so jejunum would most likely intuss into the duodenum. +  
yotsubato  Duodenum is fixed to the retroperitoneal wall, and also has lots of named vessels attached to it, along with the pancreaticobiliary duct and ampulla. It cant really intussuscept. +  
gh889  You should also know that the duodenum is almost purely on the right side of the body +24  


submitted by seagull(1404),
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embay snomoee anc leipnax yhw thsi is rvcuaaals rsiscnoe dna ton psi.sse It nedo'st ntnimoe vefre or sncaebe of eref.v hTe IRM hsa a amlls nutamo fo dsyyniehotp tbu to etg csauvraal osricsen meses /dod

someduck3  Pg 455 of F.A. mentions that alcoholism can be a cause of avascular necrosis. +5  
meningitis  I think the small dark area on the left head of femur and the darkened neck are the avascular sites. Neck: http://img.medscapestatic.com/pi/meds/ckb/15/19515tn.jpg Head: (obvious lesion on the RT femur, but similar discrete lesion on the left as seen on the practice NBME) http://radsource.us/wp-content/uploads/2005/11/1a.jpg +3  
yotsubato  He wouldnt be playing golf if he had septic arthritis. Avascular necrosis is a more chronic condition that has a slow onset. +3  


submitted by just_1more(0),
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I otg ttah ti ndedee to eb a ipomsauts ianprgs idutirc.e sI ehert a esroan it actonn be an setedoorlan tointa?snag I esohc olksbc baatroaelsl K+ hncnlesa as thees erscdeea hte ateloalbars aePKaT+AsN/+/ sbeceau het gdrnwoi fo het rtocrec wesanr idd otn eakm enses ot me -- msngsuai ehty rwee gigno fro na ENCa bkecolr nad( ttha eaecsdder llmuani iamrylietebp dniticaes that a+N uldwo be erignainm in eht ln,mue otn agimnenir in teh lipancipr ellc sa I giliyanolr o.thhut)g

luckeroo  I think the reason it’s a potassium-sparing diuretic rather than an aldosterone antagonist has less to do with why the aldosterone antagonist cannot be used and more to do with the fact that a potassium-sparing diuretic would be more of a “first-line” adjunctive diuretic treatment. +1  
luckeroo  As for the answer choice, potassium sparing diuretics achieve their overall anti-aldosterone effect by competitively inhibiting aldosterone receptors on the interstitial side (decreasing the Na/K-ATPase effect of shunting Na into the blood), thereby decreasing the gradient for sodium to enter the cell from the luminal aspect, blocking ENaC. +6  
yotsubato  There is no such thing as "Basolateral K Channel" there is only basolateral Sodium Potassium Pumps which are controlled by aldosterone. FA pg 573 +9  
nwinkelmann  @yotsubato LOL.... why didn't I think of it that what?! (by the way, that LOL is for me). The only basolateral K channel is the nephron (based on the first aid picture) is in the thick ascending limb of the loop of henle. +  
hello  Spironolactone and eplerenone are potassium-sparing diurectics that inhibit the Na/K ATPase, so I'm not sure what @luckeroo is referring to. Spironolactone and aplerenone are both ALDO antagonists. Na/K ATPase is found on the basolateral membrane. None of the answer choices fit with this. Amiloride and triamterene are also potassium-sparing diuretics; their mechanism is to block ENaC channels on the luminal membrane, this is choice "B." +1  
rxfit  From Katzung Board Review: "Spironolactone and eplerenone are steroid derivatives and act as pharmacologic antagonists of aldosterone in the collecting tubules. By combining with and blocking the intracellular aldosterone receptor, these drugs reduce the expression of genes that code for the epithelial sodium ion channel (ENaC) and Na+/K+ ATPase. Amiloride and triamterene act by blocking the ENaC sodium channels (Figure 15–5). (These drugs do not block INa channels in excitable membranes.) Spironolactone and eplerenone have slow onsets and offsets of action (24–72 h). Amiloride and triamterene have durations of action of 12–24 h." So both K-sparing subtypes are technically correct. +  


submitted by joker4eva76(25),
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ldoCu sloa use teh tpsi'enta eag ot meka teh rl.dfenefiita eAg is a srik rfctao laedetr to btaers rnccea nomcmo( ni opnpatmsus-oael mne,wo selnus htee'rs a ohyistr fo esratb nrccae ni eht ym.ia)fl

yibsForctci hneascg adn iebsdonaoamrf ear ulualsy ommocn in plnosampueare nm.eow

oN grechisad ntdeo, os is't tno an tltacniuadr loamapi.lp

yotsubato  Intraductal papillomas are also under the areola +5  


submitted by iviax94(7),
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I ugfreid yhet eewr nrtyig ot teg ta teh leif ycnxeptcae of an BCR, tub ol’dwnut ppamlsutenel O2 celntalihyc aerlecp eth CO nbdou to sC?RB FA enve enniotms htat CO isbnd ivolpitteecmy ot R,sCB nad ’ints hatt teh wehol opnti of igingv hpby0ra1e%/i0rc O?2

nc1992  First aid has a lot of errors +  
yotsubato  Thats not an error though. Thats the actual reason behind giving hyperbartic O2 for CO poisoning... +11  
mumenrider4ever  The question ask how long it takes to remove all the CO-carrying RBC so I think they're implying that theoretically not every single CO-carrying RBC would be replaced with oxygen from the supplemental O2 and some would die off naturally +  


submitted by hipster_do(6),
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I knhti ihts was efgrinrre to verrsee ttcsiarpe,nrsa dna hte only wto iverssu I wkne that sdeu hmet ewer eBpH nda i.ruHsrvsVoeeIrt/ Gniev het etnoctx I pcidke iHorerVt/vsuersI cwhih aer SS + sen.es shTi aws idkn of dreiw uhtgho ecsni teh ivsru saw ”new“ ... utb ve’I eaenrld hatt e”w“n sylulau snema vrey ltietl no htees sets.t

yotsubato  "New" means made up fantasyland virus +5  
yotsubato  Also Hep B is a ssDNA virus that goes to RNA, then is reverse transcribed to dsDNA +  


submitted by hipster_do(6),
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I htkin sthi was refigerrn to eervrse iarecp,snrttsa and the oyln wot sruevis I enwk htta edus hemt eerw BpeH adn roseH/vrtrIueV.is enivG the nxoctte I idpcek VIuies/esHrtrrvo hciwh era SS + nsees. hisT aws indk of redwi huhtog nices the srivu saw n“e”w ... tbu ’Ive lnereda atth ”nwe“ lyuaslu anems vyre ltlite no steeh ses.tt

yotsubato  "New" means made up fantasyland virus +5  
yotsubato  Also Hep B is a ssDNA virus that goes to RNA, then is reverse transcribed to dsDNA +  


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uOr tiltle fdneri sah a rPisauvovr iecfto,nni ihhwc ietfcns eotrrhidy r,upcrsoesr usgnaci prruioitentn of rrcteyhotey orpdicuont. sThi si eht esma ayw ti aussce rdyspoh letsfia in nnobur sibabe nad lpaatics amnaei ni celksi lecl, tc.e

gainsgutsglory  I get Parvo has tropism for RBC precursors, but wouldn’t it take 120 days to manifest? +  
keycompany  RBCs don’t just spill out of the bone marrow every 4 months on the dot. Erythropoesis is a constant process. If you get a parvo virus on “Day 1” then the RBCs that were synthesized 120 days before “Day 1” will need to be replaced. They can’t be because of parvovirus. This leads to symptomatic anemia within 5 days because the RBCs that were synthesized 125-120 days before the infection are not being replaced. +20  
drdoom  @gainsgutsglory @keycompany It seems unlikely that “1 week” of illness can explain such a large drop in Hb. It seems more likely that parvo begins to destroy erythroid precursors LONG BEFORE it manifests clinically as “red cheeks, rash, fever,” etc. Might be overkill to do the math, but back-of-the-envelope: 7 days of 120 day lifespan -> represents ~6 percent of RBC mass. Seems unlikely that failure to replenish 6 percent of total RBC mass would result in the Hb drop observed. +  
yotsubato  He can drop from 11 to 10 hgb easily +3  
ls3076  Apologies if this is completely left-field, but I didn't think this was Parvovirus. Parvo would affect face. Notably, patient has fever and THEN rash, which is more indicative of Roseola. Thoughts?? +4  
hyperfukus  @is2076 check my comment to @hello I thought the same thing for a sec too :) +  
hyperfukus  also i think you guys are thinking of hb in adults in this q it says hb is 10g/dL(N=11-15) so it's not relatively insanely low +  
angelaq11  @Is3076 I completely agree with @hyperfukus and I think that thinking of Roseola isn't crazy, but remember that usually with Roseola you get from 3-5 days of high fever, THEN fever is completely gone accompanied by a rash. This question says that the patient has a history of 4 days of rash and 7 days of fever, but never mentioned that the fever subsided before the appearance of the rash. And Roseola is not supposed to present with anemia. +3  
suckitnbme  @Is3076 another point is that malar rash refers to the butterfly rash on the cheeks that is commonly seen in lupus, so the face is NOT spared. +  
mdmikek89  Honestly y'all lmao First line...RED CHEEKS AND RASH Malar Erythema --- Hello? Rash - Eventually it may extend to the arms, trunk, thighs and buttocks, where the rash has a pink, lacy, slightly raised appearance Hemoglobin is 1 g/dL below normal. This is Parvo B19 -- SLAPPED CHEEK. I swear man, y'all make this easy nonsence. WAY to hard. +1  


submitted by marbledoc(0),
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yhW wluod uoy ska eth ptiatne ot eyditifn teh rpos dan nco?s I on’dt gte eth aaopphcr eehr!

someduck3  There was a question about this in Uworld. for *stubborn* patients who are "not ready to quit" just yet you use the motivational approach. The technique acronym is OARS: Open ended questions, Affirmation, Reflect, Summarize. +6  
yotsubato  Additionally the guy himself says "I know smoking is bad for me" Like he knows its bad, he doesnt care, but give him nicotine replacement and maybe he'll quit... +5  
usmleuser007  I didn't think nicotine replacement was a good answer choice b/c if he isn't ready to quit then why would he agree to use alternatives. +  
usmleuser007  People who smoke and are addicted like the feel of the cigs and environmental ques. Using replacements would be more challenging. The second best answer choice would have been Rx. +  
titanesxvi  why not detail the long-therm health effects of smoking? +  
seracen  @ titanesxvi: I assume because they always like the most "open ended" response. If you start detailing the long term effects, the patient might interpret that as attempting to convince, and might resist or feel pressured. By having the patient elucidate what they consider pros and cons, you allow it to be an open discussion. +  
suckitnbme  Also because the patient states he already knows smoking hurts him in the long run so it may come off as lecturing on something he already knows. I view this as what is the least-judgmental way to facilitate the patient moving on to the next step of the stages of change model largely of their own volition. +2  
usmlehulk  i choose the option c which is initiate a pulmunary function test. why is that a wrong choice? +2  
makinallkindzofgainz  @usmlehulk - he's asymptomatic, knows it is not good for him in the long run, but is not quite ready to make a change. It is best to talk with him about the pros/cons of cessation so that maybe he will make the decision to quit smoking soon. Ordering a pulmonary function test is not going to be useful. Let's say it's decreased. Ok, so what? It doesn't change management in this patient right now. +1  
rainlad  Think of it as motivational interviewing +1  
tulsigabbard  Still don't like the answer given that the patient already stated that he knows that it can do him harm in the long run. It seems like overkill. +3  


submitted by seagull(1404),
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uto fo us,tircoyi owh amy pleoep knwe ihts? (dotn be syh ot asy oyu did or ?tind)d

yM erotyvp aedtcouin nt'ddi agnniir isht in e.m

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  


submitted by seagull(1404),
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out fo u,ctiriyso who yma eeplop wkne si?ht ontd( be ysh ot say uoy did or tnid)?d

My trevyop ticunoead tddni' irngani shit in m.e

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  


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faeinTxom has ot be eodblemtazi aiv siftr spas mslbamiteo to na vcteai tmaoieetbl en.ifdno(x)e hTe tipeatn sah rdeeacesd nccitnresaootn of teh itaoebezdml dcpoutr nagndciiit ttah het iet’sanpt iarp fo homcotrcye 5P40 asellle atn’er zmaogeliitbn xmioteanf croryc.etl hTe uiqsoetn si ngisak htaw teh encsahc rea teh tsreis sah eth aems toynepg,e hichw owdul eb 25% g--t;& /12 * 21/ = /41

medschul  How do we know the parents are not homozygous +2  
yotsubato  Chances are they are not unless they had or are incestuous +  


submitted by joha961(43),
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Mcnainnetae edos = ssC( * CL * t) / F

... whree t si spdeela eimt enweetb oseds not( nveralte here isnce st’i ncouusnoti s)unifoin dna F is yivbaltaaibliio ciwhh( si 010% or .10 here eubaces i’ts engvi )IV.

C​rtstnao ihwt olnigda e:sod

Css( * )Vd / F

... wereh Vd si mvleou of untds.tioiibr

yotsubato  So do we just have to memorize this... +9  
gh889  yep +12  
drschmoctor  @yotsubato Not necessarily. I can't remember a formula to save my life. The Css is the amount you want in the blood. The clearance is the fraction removed per unit time. Since we want to maintain a steady state, we only need to replace what is removed. Thus, maintenance dose = amount present * fraction removed. +8  
mambaforstep  https://www.youtube.com/watch?v=gnqOUmNhmdg good & short explanation +1  
castlblack  I remember CLoCk Time as in check the clock time to give the next dose Cl = clearance, C = concentration and T = half life. I have never had to use F. +21  
baja_blast  This is on p. 233 in FA 2019. +  


submitted by haliburton(208),
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skopai sacao.rm 8.VHH esvolcoiua ul(epr)p seil.nso denvacda VIH CD4 l&;t 200 )WH.(O

yotsubato  Yeah thats the easy part. But the histology is whats hard +  


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I tgo it ndow ot niymecblo pma;& cramholublci nad ntew htwi umocbrahllci edos(und eilk na”uuflb“s ... ll)o auceseb I hthutgo yinbmocle saw rfo steraitclu isnccagenkrHd/o mo.ahymlp I laret dnufo out htat lbrcmhulocia si lalctyua a fderprree etttamren rfo !LLC sI ti scabeeu ialbruchomcl usscea erseev urioospmsne?simupn oS oyu wudln’to eb niiggv it ot a 27 oy anm in the ritsf lp?eac

yotsubato  Bleomycin is the big boy of cancer treatment. I've never heard of chlorambucil and its not in FA. +1  
vulcania  I had never heard of chlorambucil either and after researching it found out that it's also an alkylating agent, specifically a nitrogen mustard - same as busulfan, so you weren't wrong! Based on what FA says re: bleomycin & busulfan (extrapolating this to chlorambucil), they both cause pulmonary fibrosis & skin hyperpigmentation, however, in the Lange Pharmacology flashcards it says that the hyperpigmentation with busulfan is from adrenal insufficiency so I guess you would expect to see symptoms of that as well if the same applies to chlorambucil? +1  
vulcania  jk ignore my previous comment. just checked uptodate and it doesn't list hyperpigmentation as a side effect of chlorambucil. +  


submitted by yotsubato(968),
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eTh inttpae ash reuieocnptN efr.ev CSGF ilwl etosrer ihs .nehlpsrtuoi

yotsubato  His RBC and platelets are low, but at acceptable levels for someone undergoing chemotherapy. +16  


submitted by liltr(22),
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I oocehs MPV ,too btu isht ni’staept mnia tospmym is oguhc yoln nidugr .escierxe isTh si rmeo atniivedic fo iedrxeesc ctesoidaas satmh.a uYo lcudo ees rssneosth of abther ni PVM ngidru ixerce,se btu cnghioso PMV vlseae teh ugcoh uectuanodnc .fro

.ooo.   I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps. +14  
uslme123  I mean... couldn't increased BP during exercise worsen his MVP and give him SOB? +  
uslme123  (by causing slight regurg) +1  
yotsubato  "Lungs are clear to auscultation" +6  
sahusema  But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for? +  
cienfuegos  I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts? +2  
cienfuegos  Just noticed that he has FHx, game changer. +1  
kimcharito  clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise) +1  
pg32  Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP. +  
happyhib_  it took me a little; the FHx really pushed me to exercise induced. I was also looking at malingering but there wasnt a real reason to push me to this (as a doctor it would be sad to be like hes faking it becasue he doesnt want to play sports with out being sure first; led me away because there wasnt enough pointing there). Also MVP could be slightly benign and is very common and usually no Sx and his lungs were clear as was rest of exam. All pushed to Asthma +  
mittelschmerz  I think MVP on its own shouldnt cause SoB with cough (in a question, I'm sure it could in the real world). In the world of NBME questions where you need to follow the physiology perfectly, you would need some degree of MR that lead to LV dysfunction/vol overload, and theres no pulmonary edema nor an S3 that point us towards that. Malingering would have to be faked for gain, and theres no external gain here or evidence that he's faking symptoms. You would also need to r/o physical illness before diagnosing malingering, which hasnt been done. Cold weather is certainly known for exacerbating EIA and are the exam buzzwords, but any exercise can absolutely be a trigger +2  


submitted by lnsetick(90),
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I jtus bremeerm ttaSra agisny MPV edsnt to eb mtyaaisotmcp. ,Aslo I thikn eth ikd dimcpoanle ccfsliayepil of gnuochi,g nad htta deam me ylerla enal yawa ofmr VPM.

yo  he also has a family history of asthma. that's shit is genetic. +1 for asthma. +5  
yotsubato  Cheif complaint is SOB during exercise with coughing. Mitral valve prolapse is not going to do that so I picked asthma as well. +1  


submitted by hungrybox(968),
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hrteo s:asrwen

ninibiioth fo H2 crsrp:eeto for( RE)GD vnterep gstcira adic erieonsct ctenii,edmi(

iitniinohb fo hdorposesishtseepa (EP:)D

  • oheielytnhlp tsm)aah( iishnitb cAPM DPE
  • nasl-fi (kcdi psl)li for DE bniiiht cPGM DEP

2β osg:sniat for( )saathm acsue haiirbncdotnloo

  • rltbeoual orsth( ignact - A orf et)cuA
  • meltoer,als oomrlrofet lgon( ctinga - s)lpriopxyah

i(kd lmheypctoy aernebmm blstiiaan)iozt

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 haliburton(208),
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mrfo PAAF DE of dxmei aorigcn adn csncihepyog ioinrg is noc.mom nhsyecPigoc ascuse aer remo ylliek hewn het antpiet ahs narmlo iocestren htiw iunsrotbtmaa or wenh lntnucaro lepein esnmcetceu si .ormanl

yotsubato  Couldnt a psychogenic cause reduce libido? +2  
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 +7  
home_run_ball  whoops meant to comment on the other comment +  


submitted by taway(29),
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ishT esouqtin si asrephd ta,sryleng utb its' enytilsalse akinsg ta"wh lwudo ppnhea if sith as'wmon ysmidpihoothry emceab ernduclotnol vroe the soucer fo ehr cganner?"py

tnlcureyr her THS si oodg t;-&-g e-nelololtcdrlw APhOsotyyhI mTHEdLpCiYTHrio hhig HTS -;t-g& hre ohpyitohmryisd smut NTO be erntllecl-wdool u(de ot ursiodnpit of the H///TS4TTTHR3 eniedncro ixsa)

,oS own hatt we erdsnanutd taht eht niutqsoe is gsnaki h"awt uolwd pheapn if rhe hiryhmptdyioos aws "lcoleutdnro?n

werAns: nicseirtm

I tkhin hatt tihs ntquiseo si sdahper cto,yrsuiola tub fra be it fmro em to teziciirc hte MULES ncisgenil a.bd.o.r

yotsubato  I think that this question is phrased atrociously, Just like the rest of the NBME +17  
b1ackcoffee  exactly how does maternal hashimoto can cause cretinism? +  
notyasupreme  @b1ackcoffee, it's not maternal hashimoto, basically you just have to disregard the ENTIRE question stem and the last part of the sentence (if the mom's TSH goes up) means that there's hypothyroidism going on, which causes cretinism. +1  
b1ackcoffee  Thanks you @notyasupreme! +  


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mitAnmoueu tshioiidryt ak(a hosmit)Hao + &g-;nptnge-rat hkTin buato oitysblispi fo featl rsdpmoytiohyih ude to nyaobtid ddmteeai aerantlm rohoptihmyysid. eLsda ot C.isrimnet Fdingsin ni inantf are eht P'6 tPo( llyeb, elaP, fufPy cef,a nuroPdgitr ic,ublsimu orbtturePna oug,etn nda rPoo aiBnr ee.odpmeltvn

neonem  I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism? +  
poojaym  @neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4. An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland. +31  
arezpr  TSH, T3, T4 and thyroglobulin cannot cross the placental barrier. +  
chamaleo  @arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can +  
yotsubato  The baby has its own TSH though +  
sbryant6  TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work. +  
kimcharito  no goiter then? +  
lola915  I think there is no goiter because the baby's thyroid gland has not fully developed and these immunogloblulins from the mother could attack the thyroid gland leading to issues with it's development. +  


submitted by haliburton(208),
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ikln to oortcan mgraida

yotsubato  How is that NOT posterior to middle concha? bad question +10  
sympathetikey  @yotsubato - That would have been if it was the spehnoid sinus (I got it wrong too btw) +2  
niboonsh  this is a good video if u need a visual https://www.youtube.com/watch?v=mf7rY1VNy70 +3  
sahusema  Sphenoethmoidal RECESS not sphenoethmoidal SINUS +3  


submitted by aishu007(3),
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iotnvelasE in bdoy tuermtreepa urcco whne itsrtaoonncecn fo lnipnasaotdgr )(2E ))P((2EG anireecs tinwih itnreca esaar of hte ribs.hneaeT vesaeolint lraet eht iginrf reat of suoenrn that olonctr ntaouigremeohtrl in eth ahth.ymlpaosu. It si own racel ttah otms eitnitrycpsa kowr yb hitiinigbn the mezyen goclyeysxeocan and dugciner eth slevel of E2G)P( whtini het hyaholmu.stap

gb6i/wn/wt5n/pme41cn.:hv.1.uhwp6os/tbdil16.m

yotsubato  Ugh, again a concept NOT in UFAP anywhere. Bites me in the ass every time +9  
epr94  pg213 FA2019 +8  


submitted by notadoctor(151),
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Tshi osinteuq aws aignks buoat het dsrveea efcftse fo rontop mupp sniorihbit elecalysip eivgn uevporis yedkni esiss.u PPsI edesecar ursme gM nda mrsue Ca nbtrpsioao nad nca sricenea eth irsk fo ruecftar cylsipe(lae ni het leel).ryd

yotsubato  PPI therapy *begins* the day she presents. She has not taken PPI before +15  
notadoctor  You're right, I missed that! +  
naught  MEN 1 is pituitary (monitor cortisol), pancreas, parathyroid (monitor calcium) but is not the ask of this question. +  


submitted by nosancuck(85),
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Yo sdi B ogt ON AERILNNT LEMEFA ARSOGN

Why ??a!?td

We be lookni ta onsomee whit an SYR ofmr dree Y i!emeDoyrch be a Y hmrecoi emHio so eyht eb nmkia osem ssTiet einenrDmti oFtcar which I eb srue makse oems ienc lli ANTI NAUMRELLI ACROTF so dey inat got ttah aeeFlm reatInnl craTt u kown tawh i be isyna

dnA icnse mmziniw si da ATDLUEF hyet list eb itngte sode uysps lsip adn eesrsbta

meningitis  The above explanation is correct (disregarding the hard to read and unprofessional dialect) but just in case anyone was wondering: chromatin-negative= Just a quick way of knowing it was a boy. The term applies to the nuclei of cells in normal males as well as those in individuals with certain chromosomal abnormalities +16  
yotsubato  Turner syndrome patients are also chromatin negative as well though.... +5  
sympathetikey  I didn't know a complication post-meningitis was lack of humor. +5  
sympathetikey  Ah, didn't read the last line. Yeah, that is taking it a bit far +20  
niboonsh  yall are haters. this is the first explanation that has ever made sense to me +5  
arkmoses  https://www.youtube.com/watch?v=yuXL-3eoB-o&t=77s Interesting syndrome watching this helped me to put it into real life perspective, interesting points they have no pubic hair/body hair, they apparently also dont smell, and breast size is usually increased... +1  
whoissaad  How does chormatin-negative indicate a normal cell? Isn't chormatin just condensed DNA? +1  
cienfuegos  According to this paper most individuals with Turner Syndrome are chromatin negative: "One of the initial laboratory procedures used to confirm or rule out this diagnosis involves a sex chromatin determination from a buccal smear. Cells from the lining of the mouth are stained for the presence or absence of X-chromatin or Barr bodies, which represent a portion of an inactivated X chromosome. The typical Turner’s syndrome patient, who has 45 chromosomes and only one sex chromosome (an X), has no Barr bodies and is, therefore, X-chromatin negative. This abnormal X-chromatin negative finding in the majority of Turner’s syndrome females is similar to the result found in a normal male, who also has only one X chromosome, and differs from the X-chromatin positive condition observed in the normal female, who has two X chromosomes. Occasionally, the patient with features of Turner’s syndrome is found to be X-chromatin positive." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233891/ +1  
hyperfukus  i really hate haters this is awesome! +1  
selectuw  to add to the above, free testosterone is aromatized to estrogen leading to breast development +  
misrao  Is the free testosterone not creating male internal or external gentalia because of the defect in androgen receptors? +  


submitted by haliburton(208),
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FA :7012 nrioChc oihpxyc yuopanrlm tioccisrtoavnons rtesusl ni alyormpnu sntyneopehir dna RH.V

yotsubato  Yeah but in a chronic case this guy would produce more RBC and not be hypoxic anymore. +20  


submitted by hayayah(1056),
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yyctesienie-etCsn heimnokec rortpeec 5 CC(5R) is a onpreit onfud no the racusfe fo D4C clsle.

yotsubato  Note, this is NOT in FA +2  
sbryant6  It is in UWorld. +3  
almondbreeze  it's in FA2019 pg.110 +1  
almondbreeze  but missing the full name for CCR5 +4  
demihesmisome  CXCR4 is also a chemokine receptor. +2  


submitted by cantaloupe5(72),
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Tshi noe asw cyitrk utb I hnikt you el’ocvdu nedo thsi oen hutwito elkwdneog fo ANMD sc.ertpero mtSe ldto uoy ttah meluatatg aatcsvtei bhto MN-DonAn dan DAMN ptcorsere ubt it tieaatdcv only nAMDnN-o esortrcep ni hte rlaye hap.se htaT amsen ADMN rretcspoe taivecat tfaer MnonDAN- tre.oerscp Thta ansme toisnhgme aws idnlgeay MDAN cpreorte navgcttaii adn teh lony srnewa hatt dema nsees sa het gM tbninhiiig ADNM ta gresint atotp.ieln ncOe teh cell is eealrzdidpo yb ADNMo-nn porsrc,eet MAND tcporrsee acn be aivttec.ad

hungrybox  I forgot/didn't know this factoid and narrowed it to the correct answer and a wrong answer. Guess which one I chose? +11  
yotsubato  >That means something was delaying NMDA receptor activating and the only answer that made sense as the Mg inhibiting NMDA at resting potential. What makes the fasting gating kinetics choice incorrect then? +5  
imgdoc  NMDA receptors are both voltage gated and ligand gated channels. Glutamate and aspartate are endogenous ligands for this receptor. Binding of one of the ligands is required to open the channel thus it exhibits characteristics of a ligand channel. If Em (membrane potential) is more negative than -70 mV, binding of the ligand does NOT open the channel (Mg2+ block on the NMDA receptor). IF Em is less negative than -70 mV binding of the ligand opens the channel (even though no Mg2+ block at this Em, channel will not open without ligand binding. Out of the answer choices only NMDA receptors blocked by Mg2+ makes sense. Hope this helps. +6  
divya  sweet explanation imgdoc +  
lovebug  really~~~ sweet. thankyou :) +  


submitted by tinydoc(223),
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Tpey 1 aFllmiai ispdleaiiymD p(g. 49 AF 91 )

irnaeedsc GT &--t;g- ntiacisaretp ueiE ctrp / utrsrpii hXaaanntds om SHM

nCa eb uceads by prtLoeoinip plseia ro nrotippAeo IIC cyidifence

ehty dasi ttha LPL si fine os ist AOP CII

anepHir eeetsprsa PLL rfom rparienH taSfelu teiMyo on acVs umhioedntlE igonllaw su to tset tis ucointnf ni the .alb

I gto ti gronw oot - tipSdu Rteo oitazmmeroni ecrlla Qneut.ios

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  


submitted by priapism(6),
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Per First :diA naibitdeso itaagns AOB oodbl pseyt dten ot eb gMI ro IG,g hwchi si why hte wnraes is GIg + cmeeoptlnm dan ton IgA + lctnmmopee

yotsubato  IgA also has no role in any hypersensitivity reaction +2  
divya  hi. where is this given in first aid? +  


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udyihoert sikc mdesyorn si osmtiemes alceld o"wl T3 eso.y"rdmn slAo you wnko ttah the ttapien is tyudrohei ceubeas ehr T4 nda HST rea niitwh the cnerefere .nerga eSh si ksci.

yotsubato  This is not in FA btw. +9  
niboonsh  https://www.ncbi.nlm.nih.gov/books/NBK482219/ probably caused by her recurrent pneumonia +3  
eacv  I though in this one as a sick sinus syndrome hahaha in UW. +  
pg32  Pretty sure boards and beyond teaches this wrong. Dr. Ryan says that in euthyroid sick syndrome T3, T4 and TSH will be low, but rT3 will be elevated. +  
pathogen7  In reality, TSH and T4 levels can be highly variable based on the stage of Euthyroid sick syndrome. One thing that happens for sure, I believe, is that T3 is down and rT3 is up. +1  


submitted by aesalmon(81),
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I tenw kcab adn dchetwa hits ntiosce no hapaotm refta egnigtt hte uontieqs gnwro - Dr. traSat sasy atht hraCsdnmoo adn ohasrondrcmsoCa eairs ni het ,MEDLUAL adn ont teh oe.rtxc vreoweH the oetqusin tmes attses ahtt ehtre si iecntkhing" of eht aisshidyp adn toipidurns of het ETCXRO ihwt flaco arae fo deceansir itia"cnac,iflco ???

yotsubato  It arises in the medulla and *passes* through the cortex because its invasive and malignant. +12  


submitted by hungrybox(968),
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lnlogFwio a kost,re hist taepitn dah wnkesesa of rhe flte acef nda bd,yo os hte seotrk mtsu veha afefcdte het rihtg desi of her niba.r B wsa eht ynol hiceoc on eth gthri dise fo rhe brain.

Sillt dsfencou? deRa ..no.

Teh vlatonruy otmor fesbir nictp(cirosalo )ttarc ncsdede rofm hte raiymrp omtro eotr,cx ssroc d)csseae(tu at eht ydellraum samidy,rp nad nhte nepsysa at hte rontreai motro hrno of eth lpnasi e.evll

aBeuesc fo cdastiouesn ta het yalmurlde pr,ysaidm yuo hlodsu ekma a oent of eewrh yna rtksoe sorc.uc Is ti vobea het aullmrdye ?spmyradi nheT ti lliw cftafe the dsei piopeost eht roetsk )lc(en.tortarala sI it ewblo the reulmlday yrsmdp?ia nThe ti lliw caetff the mesa ised as the toerks i.aril)pasl(te

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +7  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +16  


submitted by sympathetikey(1252),
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hecCoi .A woudl haev bene creortc fi tihs atpetni saw .riudsnoeopmcmiomm ePr rsiFt Adi, If" C4D 0lt,;10& liesntar:..io.gnFlaBdn hNuliirpocte o.iaalImfnmtn

How,eerv as hits tpeitna ahs a totceempn emmniu systm,e zzub ordws ear atletels onzrtcigien mgsoulrana.

yotsubato  Everyones choice A is different. +  
sugaplum  they mean- Diffuse neutrophil infiltration +1  
macrohphage95  what does stellate necrotizng granuloma means ? +1  
krisgsxr600  always with the details! losing dumb points :( +1  
futuredoc12345  @sympathetikey Doesn't the biopsy finding vary with the biopsy location: Lymph nodes have stellate granulomas and Bacillary Angiomatosis (skin lesion) has neutrophilic inflammation. What do you think? +  
chextra  @sympathetikey Pathoma chapter 2 says cat scratch disease forms non-caseating granulomas +1  
almondbreeze  @ chextra Same with FA 2019 pg. 218 +2  
almondbreeze  Sketchy micro: Immunocompetent: regional LN in axilla in one arm (like our pt here) Immunocompromised: bacillary angiomatsis is transmitted by cat scratches +  


submitted by laminin(14),
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anc meosneo eaxlpni ywh it ayss eh ash an atnict'' PHT i.ase.ctroncnn.ito ti ot lte us knwo ttah eth PHT nnooncictreta is a sretul fo tdny?pghalaoo hwa'ts ihs d?x t!akhns

yotsubato  I swear they make up some of this stuff. Like whats up with the thirst, urination, and peptic ulcer diseases. +6  
redvelvet  hypercalcemia can cause nephrogenic diabetes inspidus; so thirst, urination. hypercalcemia can also cause peptic ulcer disease. His symptoms are all about hypercalcemia due to hyperparathyroidism. +2  
namira  "Hypercalcemia can cause renal dysfunction such as nephrogenic diabetes insipidus (NDI), but the mechanisms underlying hypercalcemia-induced NDI are not well understood." https://www.kidney-international.org/article/S0085-2538(16)30704-9/fulltext +  
dulxy071  Why can't the correct answer be C) which points towards renal failure, which may lead to secondary hyperparathyroidism having the same results I believe +1  
pmofmalasia  The secondary hyperparathyroidism in renal failure is due to loss of calcium in the non-functioning kidney. In this question the calcium was elevated, so you can rule out renal failure. +  
sars  Hyper-calcemia causes stones (calcium stones), groans (constipation), thrones (increased urination), bones (increased osteoclast activation), and psychiatric overtones (depression). +  


submitted by killme(13),
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eTh onccpte engib destte is tw"ah seod TPH do ahtt eldsa ot ml"cerpceyaiah/gc/.st/aK:btsoiep/hd.bPgniVp.i3jm

yotsubato  ugh, bullshit. I was trying to figure out an actual disease process here. +4  
rio19111  its primary hyperparathyroidism caused by parathyroid adenoma. addition of the peptic ulcer suggest Zollinger ---> MEN1 but none of that is imp because that's not what they are asking. All they are asking for is the function of PTH. +2  


submitted by xxabi(251),
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Benonoichrcg narmocica = gunl ceancr

hTat bgine ,asid unlg mnocdnoaaaeric iapycclifsel is ssecadatoi hwit hiorrhpyepct aorhsoptayre,thto ihwhc is a ntisoepralpaca roysednm rziceaedcrhta yb igtiadl inulbb,cg rtaihrlag,a onjit ufosnf,ies and opresssitoi fo ulrtuba besno

luke.10  why not systemic scleroderma since i did this question wrong and i chose systemic sclerosis scleroderma , can someone explain that ? +2  
kernicterusthefrog  My best guess answer to that @luke.10 is that: a) there's no mention of any skin involvement (which there would be in order to be scleroderma) b) Scleroderma shows pitting in the nails, not clubbing c) There would be collagen deposition with fibrosis, not hypertrophy of the bone at joints Saying that, I also got this wrong! (but put RA...) so I'm not claiming to "get this" Hope my thought process helps, though! +6  
yotsubato  This is in FA 2019 page 229 +9  
larascon  I agree with @kernicterusthefrog on this one, Bronchogenic carcinoma = lung cancer. Squamous cell carcinoma gives you hypercalcemia (new bone formation; maybe?), commonly found in SMOKERS ... +3  
waterloo  the clubbing is the symptom that takes out alot of the answer choices. It's super tricky. +  
jawnmeechell  Plus the patient has an 84 pack-year smoking history, super high risk for lung cancer +  
veryhungrycaterpillar  FA 2019 pg 229 is all paraneoplastic syndromes. There is no mention of bronchogenic carcinoma in any of them. There is adenocarcinoma, but that is most likely in non smokers, not in someone with 84 pack year of smoking history. Why does he have 5 upvotes for referencing first aid here, what am I missing? +2  
jakeisawake  @veryhungrycaterpillar sounds like bronchogenic carcinoma is a general term for lung cancer. You are right that if a non-smoker gets lung cancer it is most likely adenocarcinoma as non-smokers rarely get small cell. However, smokers can get adenocarcinomas as well. The oncologist that I shadow sees this frequently. Adenocarcinoma of the lung causes hypertrophic osteoarthropathy per 229 in FA2019 +2  
mangotango  @verhungrycaterpillar @jakeisawake Adenocarcinoma is the most common tumor in nonsmokers and in female smokers (like this patient), so adenocarcinoma would still be the most likely cancer for this pt over the others. Pathoma Pg. 96. +3  
fatboyslim  Apparently bronchogenic carcinoma is basically an umbrella term for lung cancer. Source: https://radiopaedia.org/articles/lung-cancer-3 +  
lifeisruff  bronchogenic is another term for adenocarcinoma in situ according to pathoma +  


submitted by celeste(78),
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iThs sunods klei iFocann mnerd.oys Teh amprioxl abtuurl ihelailtpe lescl vhea a dhar tmei ogernasbrbi irlefatt, so uylo'l ees a sols of aotshpep,h oianm sacdi, rao,ebtciban adn sg.eculo

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +4  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +1  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +1  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +  


submitted by beeip(123),
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thTgohu iths ldwou be ihonsemgt gniraerdg rari"aticb eg"yrru,s tbu ,onep sutj o"n hcastyr soo,df uasebce eour'y dr.be"aecitp-i

hello  Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +  
yotsubato  such a BS question IMO +5  
yotsubato  such a BS question IMO +  
breis  I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +4  
teetime  This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +2  
dr_jan_itor  Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1  
dhkahat  yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +  


submitted by beeip(123),
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hTohtgu hist uoldw eb mntosiheg ngiaegdrr tarib"airc "es,rryug btu pn,oe ujts o"n acrhyts ood,fs ebsueac yreou' ie.ctpibd"-ear

hello  Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +  
yotsubato  such a BS question IMO +5  
yotsubato  such a BS question IMO +  
breis  I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +4  
teetime  This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +2  
dr_jan_itor  Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1  
dhkahat  yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +  


submitted by neonem(550),
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lhileSga usacse an ortflmayaimn ieah;rard it sdoecrpu a otnxi dna nca iednav ssteui lcrdyei.t In i,ddoaint it si tsneasitr to ciad, so ti sah a sicatchliraylterac wol eicenvfit sedo 01(~ ,anmgsisor) chiwh etacitaflis its celolfaar- ns-retornpe)po-s(o pardse yleisaepcl in etinsgts erhew iyehneg may eb rmciomdospe, cshu as ni aedryac ro aouttsntiliin gosnui.h It nac eb nrfeeieaidttfd morf E. oliC C)(HEE baecseu E loiC soed'tn vhea sa hucm e-eosror-notppns asrepd adn yonl scseua GI gmaaed by hte -lehsagiki ni,tox not itrcde iinnsoav. efrTehoer, HECE lto'undw aeilaftitc sa gostrn fo a ipchnuteoilr pnsser.eo

yotsubato  I assumed all the kids in the daycare had the same lunch, thus got food poisoning, thus all got EHEC. +3  


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nI pocheginysc iypiadplos, uerms dmuois si o,lw nda taref rwtae diinvtoreap t,set eruni ayllomoits is rs reincdeiU.ane maosoltyli esdo nto rsaceine hwti rsspesoivan jntcinioe

nI cheogpneirn sideaebt inpiui,ssd smrue uiomds is hghi nad ethre si on agil/enhdcm eacrnesi in nruie ilsaoolymt treaf awret tineivpdaor

yotsubato  This patient does not undergo a water deprivation test +12  
niboonsh  Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric populations. Effects of increased water intake can lead to hyponatremia causing symptoms of nausea, vomiting, seizures, delirium and can even be life threatening if not recognized and managed early. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579464/ +7  
missi19998  Just wondering why it in not resistance to ADH action of vasopressin +  
amarousis  because he would be hypernatremic with no ADH. can't resorb any water +1  
minhphuongpnt07  low osm/urine, low os/plasma => psychogenic polydipsia +  
benitezmena  In this question the pt had a normal urine osm (80) a low urine osm would be <50mosmol/kg. +  
euchromatin69  u world 212 +  


submitted by strugglebus(163),
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orweNhe ahev I nbee leab to idfn why eth lhle htis is a .ginht

yotsubato  Its not in FA, Sketchy, or Pathoma, or U world. I knew it wasnt cancer because its bilateral. And Diabetes made no sense to me. So I just threw down Drug effect and walked away. +6  
breis  same^^^ +  
feliperamirez  The only possible explanation I think is that she was under a K sparing diuretic, such as spironolactone (which would lead to gynecomastia). +  
chandlerbas  you had me at its not in sketchy ;) +1  
j44n  i thought HTN induced empty sella would cause this because they got type II diabeetus. So if you need a pro zebra hunter holler at me. +  


submitted by hayayah(1056),
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nscvauraeolR ieesdsa si the tmso ncmoom cseua of 2° NTH ni u.dlast naC eb t/d imeisach morf nlrae oensists or raavmsclrucio e.isadse anC hear arnle rbstiu ltralea ot lbuuisicm.

aMni cseaus of enalr retyar soni:tess

  • erisleccooAtrht lpeaaxqos—iulmpr 1dr/3 feonla r e,rayrt sayulul in oedlr eam,ls .orsksem

  • cosliumrbFrua py—tdlslaasiisda rd3/2 ol arfen tyaerr ro sgtnaelme erna,chbs yal suluuyngo ro mdagde-ldei efem.lsa

baL lesuva absde f:of

  1. ntiSseso eraecseds lobdo lwfo to relusgoul.m
  2. lrlgtxmauuroaJe aspauprta (JGA) eosprsdn by cnertisge ein,nr cihhw osctrnve eansnootiinngeg to gnisnentoai I.
  3. iAnistgeonn I is otecrvdne to ateniongnsi II (IATI) yb agnoniinste tnceinogvr zyeemn CAE( i-n- )nugls
  4. TIAI esasir lbodo errspseu by 1() gnctcniaort aielrroatr smtooh sumcl,e egnisanicr ltota iapelerphr enatcersis nad 2)( trgomopin endalar aseeelr of tdresna,oelo wchih saerisnec airopnetosrb of smoiud eeh(wr +Na esgo H2O will olwf)ol ni eht atdsli uocnlotdve tulube pdxg(innae pmalsa umlevo.) Can ldae to opkalehyaim ns(ee ni eht lsba fro htsi q)nuitose
  5. adLse to HTN htwi ceidneras lpsmaa einrn nad eluanralit yoahtpr (ued ot olw blood )lwfo fo teh tdefface edk;yin retnieh rtfeeua is nese ni yairmrp yreotpnesnih
uslme123  So both causes would result in increased aldo and MR is the only way to differentiate the two? +2  
hello  @USMLE123 I think both are causes of renal artery stenosis and that could be seen via MR angiography. It is asking what could help DIAGNOSE this patient -- and her most likely cause of the findings is fibromuscular dysplasia. So, yes, MR angiography would look different for the 2 different etiologies and thus could can be used to differentiate the two from one another. However, epidemiologically, we are looking to diagnose her with the suspected most probable cause. +8  
yotsubato  @USLME123 I think measuring Aldosterone is an incorrect answer because you already know its increased due to low K. Knowing she has high Aldosterone wouldnt provide you evidence for a final diagnosis. +4  


submitted by hayayah(1056),
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aiateCpt adn unalet rae in eth etcner fo het .amlp eCaitpat si ton na ipt,ono os nltaue si eth answre.

oaDlicnitso of eultna may ceaus utcea rt nlalnaucep enmryso.d

yotsubato  Lunate is the only carpal bone that is frequently dislocated. Scaphoid is frequently fractured. Hook of hamate is also frequently fractured. +3  
redvelvet  and also point tenderness in the anatomical snuffbox may indicate a scaphoid fracture. +3  
chandlerbas  yes lunate is the most common dislunated carpal bone ;) +4  
almondbreeze  FA 2019 pg. 439 : dislocation of lunate may cause acute carpal tunnel syndrome +  


submitted by strugglebus(163),
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,KO so fi I mermeber clcrotyer hsti si hte neo atth hwsso hte naiitcehnre arnet.pt mthrnodcoilia si olsa apessd yb hte rh;eotm eorvhwe, ti anc have vabirale prysitvexsie and mtceeinlop aepenrect,n wihhc is hwy semo smeermb rwee ont ceafef.dt

hyoscyamine  Also, question said there was a deficiency in NADH dehydrogenase activity which is another fancy way of saying complex I in the mitochondria. +13  
yotsubato  That unaffected male really threw me off... : ( +20  
charcot_bouchard  It was pure MELAS description. the unaffected male threw me off +2  
mbourne  I think the affected male on the right side is actually a helpful hint. Mitochondrial conditions can be inherited by males or females, but are only passed on through the females. +1  


submitted by hayayah(1056),
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lnaIniug ihensra aer alluysu brel,iucde efmalor nsahrei are on.t

ishT si na ierdntci laniiung .eirhna It esentr lnteiarn inuaginl ignr llteraa ot orfernii pciegarsti sseslev and si rouperis to eth ilgnunai ltanmeg.i

usCead by leufari fo scsrpseou iganisalv ot cleos nc(a mrfo lhecryd).eo aMy be cndieto in tnniasf or dsdcreoeiv in olhda.oudt hucM omer monmco in emlas.

yotsubato  Heres a good picture to help with the concept. https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwjVkIi0yN7iAhWLjqQKHbeXCTUQjRx6BAgBEAU&url=https%3A%2F%2Fwww.herniaclinic.co.nz%2Finformation%2Ftypes-of-hernias%2F&psig=AOvVaw2BzGtQLvSmUN8ymhdvETG5&ust=1560244112252834 +4  
sbryant6  Note that direct inguinal hernias typically happen in older adults. This question presents a younger baby, so it is more like to be indirect. +7  
jawnmeechell  So a femoral hernia would be inferior to inguinal, but direct/indirect would be superior? +  
azharhu786  The direct and indirect hernia are both superior to the inguinal ligament but the femoral hernia is basically inferior to the inguinal ligament. The direct hernia is medial to the inferior epigastric vessels whereas, the indirect is lateral to the epigastric vessels. An indirect hernia is seen in young people whereas, direct hernia happens in adults. +4  


submitted by hayayah(1056),
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asCe fo rssllasrt.ocoeioeri

eHsiyatlprpc liatiresrrooelsocs sievlnov heiitgknnc fo sseelv awll by sahplrpieay fo ohsomt clmseu i's(noion-kn a)'npaaerecp

  • Cuncqseenoe fo nanatmgli pteynoerhnis 1t0/&g20(18; w/ tcaue ernngd-oa adaegm)
  • sRultse ni cereddu evessl lcrabei whit aenr-gdno iaichems
  • aMy aled ot ridinboif snrcieso of the levess wlla wthi eerorma;hhg lyiaaclsscl scasue etuca lnear afrieul (RFA) thwi a acatcstiircehr ife'tntlba-e' acanpeerap
masonkingcobra  From Robbin's: Fibromuscular dysplasia is a focal irregular thickening of the walls of medium-sized and large muscular arteries due to a combination of medial and intimal hyperplasia and fibrosis. It can manifest at any age but occurs most frequently in young women. The focal wall thickening results in luminal stenosis or can be associated with abnormal vessel spasm that reduces vascular flow; in the renal arteries, it can lead to renovascular hypertension. Between the focal segments of thickened wall, the artery often also exhibits medial attenuation; vascular outpouchings can develop in these portions of the vessel and sometimes rupture. +  
asapdoc  I thought this was a weirdly worded answer. I immediately ( stupidly) crossed of fibromuscular dysplasia since it wasnt a younger women =/ +16  
uslme123  I was thinking malignant nephrosclerosis ... but I guess you'd get hyperplastic arteries first -_- +  
hello  The answer choice is fibromuscular HYPERplasia - I think this is different from fibromuscular DYSplasia (seen in young women); +23  
yotsubato  hello is right. Fibromuscular hyperplasia is thickening of the muscular layer of the arteriole in response to chronic hypertension (as the question stem implies) +6  
smc213  Fibromuscular Hyperplasia vs Dysplasia...... are supposedly the SAME thing with multiple names. Fibromuscular dysplasia, also known as fibromuscular hyperplasia, medial hyperplasia, or arterial dysplasia, is a relatively uncommon multifocal arterial disease of unknown cause, characterized by nonatherosclerotic abnormalities involving the smooth muscle, fibrous and elastic tissue, of small- to medium-sized arterial walls. http://www.medlink.com/article/fibromuscular_dysplasia +1  
smc213  *sorry I had to post this because it was confusing!!!*Fibromuscular dysplasia is most common in women between the ages of 40 of and 60, but the condition can also occur in children and the elderly. The majority (more than 90%) of patients with FMD are women. However, men can also have FMD, and those who do have a higher risk of complications such as aneurysms (bulging) or dissections (tears) in the arteries. https://my.clevelandclinic.org/health/diseases/17001-fibromuscular-dysplasia-fmd +1  
momina_amjad  These questions are driving me crazy- fibromuscular dysplasia/hyperplasia is the same thing, and it is NOT this presentation and it doesn't refer to arteriolosclerosis seen in malignant HTN! Is the HTN a cause, or a consequence? I read it as being the cause (uncontrolled HTN for many years) If it was the consequence, the presentation is still not classical! -_- +1  
charcot_bouchard  Poor controlled HTN is the cause here +  
charcot_bouchard  Also guys if u take it as Fibromuscular dysplasia resulting in RAS none of the answer choice matches +