NBME 17 discussion

[fatwalletuab]

Can you guys correct me on this
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8.old woman with DVT. Platelet dropped significantly after a week of tx. Drug of action?
a. activate tissue plasminogen -----action of tPA
b. Interferes with carboxylation of coag factors ----action of warfarin
c. irreversibly inactivate COX -----Aspirin
d. Potentiates the action of antithrombin iii (correct answer, action of Heparin, and this is Heparin induced Thrombocytopenia HIT)
e. selectively inhibits factor Xa (Heparin does thrombin factor 2 and factor Xa)
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14.ER doctor successfully delivered a baby, womanis now having severe bleeding. Pelvic exam shows an ope cervix and heavy vaginal bleeding. Ligation of a branch of which of the following arteries is most appropriate?
a. external iliac (gives femoral and inferior epigastric artery)
b. internal iliac ( Correct answer I think, bcz Uterine artery is a branch of internal iliac artery)
c. internal pudendal (supplies the external structure, but also a branch of internal iliac)
d. median sacral (supply coccyx)
e. Obturator (gives blood supply to the leg obturator muscles)
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16. A patient cries ad says it's a bad news, isn't it?! when a doc is about to tell him the progression of carcinoma to the terminal phase. Most appropriate response?
a. How have you been since the last time I saw you?
b. lets talk about hte positive aspect first
c. look on the bright side of things
d. tell me how you are feeling
e. there are other people who have it alot worse than you
f. Yes it is
g. you've had several years better off than many others with this disease.

I was debating on A or D. I picked D and it's wrong....is that bcz it didn't end with a question mark? wth
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32. A guy with chrons disease. You give antibiotics and prednisone, he got better in 3 weeks, in addition to resolving the infection, the most likely MOA of this pharmacotherapy is which of the following?
a. antibody binding
b. complement activity
c. mast cell degranulation
e. neutrophil function
f. T-lymphocyte function

I marked e. but it's wrong....so I'm guessing T-lymphocyte fumction F? as to decrease T and B cell couns. However, neutrophil count is increased.
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10. 45 year old lady diagnosed with invasive ductal cell CA breast . she was started on tamoxifen and serum analysis showed decreased conc. of enoxifen the active metabolite of prodrug tamoxifen. Genetic analysis showed homozygous presence of CYP450 2D6*4 alleles. WHich of following best represents the likelihood that this patient sister has same alleles?
1.0% 2. 25% 3. 50% 4. 75% 5 100%
Can anyone solve for this one??? thanks!
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49. Old man with 2 year history of decrased force of his urinary stream and increase frequency. BUN is 55 and Creatinine is 5. Ultrasound of Urinary tract shows bilateral hydronephrosis and dilated ureters. What is the mechanism of this patient's renal failure?
a. Decreased hydrostatic pressure in the glomerular capillary
b. decreased renal plasma flow
c. Increased hydrostatic pressure in Bowman space
d. Precipitation of protein in the renal tubules
e. Precipitation of uric acid in the renal tubules
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4. A 27 yo woman with fever, malaise, abdominal pain, vaginal discharge for 4 days. Pregnancy test is negative, Leukocyte count is up. Bilateral lower quadrant tenderness with rebound and guarding. Pelvic exam shows cervical bilateral adnexal tenderness. Most likely diagnosis?
a. appendicitis
b. bacterial vaginosis
c. Chancroid
d. Diverticulitis
e. Gonorrhea
f. Herpies genitalis
g. Trichomonias

Gonorrhea...I picked chancroid on the exam...because I thought chancroid can have those bubonic thing bilaterally....i guess the answer is gonorrhea?!
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6. A study is designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in pts with CHF. 60 pts with CHF are recruited for the study. Each subject is assigned by coin toss to one of two groups (standard care or standard care plus coenzyme). Which of the following best describe this study design?
a. case-control
b. case-series
c. Crossover
d. Cross-sectional
e. Historical cohort
f. Randomized clinical-trials

I'm guessing F. is the correct answer bcz by giving q10, you're giving a treatment (intervention) to the study. And the coin toss gives the randomness.

a. Case-control: have 2 groups, one health as the control and one diseased. Trying to evaluate the risk factor. So the example will be: 60 pt with CHF drink more and smoke more. Healthy individuals smoke and drink less. Risk factors are smoking and drinking alcohols.
d. Cross-sectional: snap shot, trying to find out in a population who have CHF. You know the prevalence but not incidence.
e. I don't think it is either retrospective or prospective
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A guy completed amoxillin develop watery-brown stools in the past 24 hours. Clostridium difficile toxin is positive. Pathological finding is most likely to be present?
a. Bacterial Overgrwoth of the colonic surface
b.Flask-shaped ulcers in the colon
c. Giardia trophozoites linning the duodenal mucosa
d. Necrotizing granulomatous inflammation
e. PEsudomembranes of fibrin and inflammatory debris

They want us to pick e. But I have seen many qbank and wiki sources say a). Can someone tell me why not AAAAAAAAAAAAAAA??
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A 1 week old girl screening sho a possible defectin fatty acid oxidation, physical exam shows no abnormality. Which of the following is the most appropriate next step in diagnosis?
a. arterial blood gas analysis
b. measurement of serum acylcarnitine conc.
c. measurement of serum amino acid conc.
d. measurement of serum electrolyte conc.
e. measurement of serum lactic acid conc.
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34. 40 yo woman has a mole on her back that has increased in size during the past 4 mo. PE shows Raise irregular lesion with variegated black-tan pigmentation and ill-defined margins. Examination of tissue from the tissue shows pleomorphic, hyperchromatic cells within clear islands that tend to coalesce and are present at all levels of the epidermis, with extension into the paipillar dermis. What is it?
a. basal cell carcinoma
b. blue nevus
c. cafe au lait spot
d. intradermal nevus
e. lentigo simplex
f. melanoma
g. seborrheic keratosis

I think it is f melanoma

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7. A 42 year farmer has a 7mm red scaly plaque on helical rim of left ear . A photomicrograph of tissue obtained on biopsy of plaque is shown. whats the diagnosis ( Picture was shown)
a. Actinic keratosis b. Basal cell CA c. Keratocanthoma d. Malignant melanoma e. Merkel cell CA

I think it's a. actinic keratosis

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[lualce]

Hello people I want to know this question that i don't understand:

A 10 year old boy has had anemia since birth. His spleen is five time times normal size. Splenectomy is indicated if the anemia is caused by which of the following disorders?
a) Fanconi anemia
b) Glucose 6 phosphate dehydrogenase deficiency
c) Hereditary spherocytosis (is this the answer?)
d) Sickle cell disease
e) Thalassemia major

All of this are indication for splenectomy, isn't it or am I thinking too much in this one.

 

[lualce]

Answer are in Bold

I apologize in advance if any of these questions have been repeated. I would appreciate any help I could get. Thanks for the correct answer and an brief explanation!

1) Patient is 30 y/o 22 weeks gestation. One day history of fever, chills, and muscle aches. Fever, high pulse, and low BP. Uterus size is consistent with gestation. Fetal heart sounds present. Leukocyte count 12,000. Blood cultures show gram positive rods What the organism that causes this? B. cereus, C. perfringes, L. monocytogenes, S. aureus, Group B strep. (In pregnant if you see a vignette like this one always link it with L. monocytogenes).

2) Patient is 9 y/o with poor growth and weight. Bitemporal hemianopsia. Labs show GH deficiency. MRI shows calcified cystic mass in suprasellar region. Tumor is derived from which of the following? Diverticulum of the roof of the embryonic oral cavity, Ependymal layer of the median eminence, Hypophyseal cartilage, Neural crest cells of the rhombencephalon, Neuroectoderm of the diencephalon. (Craniopharyngioma given her age).

3) Patient is 38 y/o 1 week history of water, itchy eyes and runny nose. He is a crane operator. PE shows inflamed nasal mucosa. No congestion in lower lung. Treatment? Bromopheniramine, Diphenhydramine, Hydroxyzine, Loratadine, Ranitidine (the 3 one are first generation anti Histamine which have antimuscarinic effect and it wouldn't hel him since his job is a crane operator and Ranitidine is for peptic ulcer disease).

4) Patient is 50 y/o college professor smokes, works out and eats right. Diagnosed with lung cancer. Patient is in disbelief asks "How can this be happening to me? I eat right and exercise." Whats the appropriate response? Dont, worry I will be there for you and make sure everything turns out the way you want. Eating right and exercising will not prevent cancer. In fact, as you probably know, the major risk factor for lung cancer is smoking. It must be difficult for you to accept this diagnosis when you feel healthy. Regardless of your good habits, its time to realize that you have lung cancer.

5) Patient is 24 y/o just had unprotected sex recently with a new partner. Small tender blisters on his penis. Some of the blisters broke and left open sores. Whats the offending agent? Calymmatobaterium granulomatis. C. trachomatis. H. ducreyi. HSV-2. T. pallidium. (I don't remember the picture but I think I picked this one and it didn't come back in my incorrect.)

 

[talidoc]

--MOA of cyclosporine:

a) Blocking recognition of antigens
b) forming 6-thiouric acid and blocking metabolism of nucleic acids
c) increased production of interleukin by T cells
d) suppressing the activation and production of B cells (incorrect)
e) suppressing the early response of T cells to activation (I'm assuming this must be correct but I thought this was how sirolimus works?)

--Patient that should be on insulin but thinks it will make him sick bc of family experience. Is this contemplation?

--The skin cancer slide, can anyone explain why it's actinic keratosis? Is it because there is no invasion of the basement membrane? Why isn't it keratoacanthoma?

--Splenectomized patient is most susceptible to infection with which organism?

a) Candida
b) CMV
c) E coli
d) HSV
e) Strep pneumo

I was debating between S pneumo and E coli and went with E coli, can anyone explain why E coli is wrong?

its e ) S pneumo

 

[talidoc]

I think the most right answer is A, going for biopsy +/- CRP. It's extremely unlikely that ESR would be falsely elevated as high as 100, and it commonly reaches levels that high in TA. So a repeat ESR would be useless acutely, IMO. I think they are trying to get at something with the stats here, as the post-test probability is ~71%, but I don't know what that means as far as next best step. The best answer would be B if not for the 99% certainty part, because you would want to treat empirically while waiting on biopsy results to reduce risk of permanent vision loss. I don't see repeating an ESR as beneficial as you would still have the same rate of false positives if you thought 100 could possibly be a false positive.

answer b is wrong

 

[blackswan5]

Does anyone know the answer to the question in which a 15 year old girl came to the physician with family history of skin cancer. The physician recommended methods of photoprotection including daily use of sunscreen. In a patient of this age, which factors is most likely to predict compliance to photoprotection?
A.ability to tan
B. Advice of the physician to wear sunscreen
C. concern about premature aging of skin
D. Desire to prevent sunburn
E. Family history of skin cancer
F. Use of sunscreen by her peers
Thank you in advance

 

[justadude01]

1. C, very common cause of anemia is older person is GI blood loss. Different sizes of RBCs would give a wide red cell distribution width (RDW) which implies blood loss. The other answers do not make sense with the rest of the question stem. (A) would have pancytopenia, (B) would likely have a higher WBC and smear would have leukemia-looking cells, (D) would be severe microcytic anemia and would not be presenting now at age 72, and (E) no history to correlate with B12 deficiency/ no megaloblastic cells.

2. D, endometriosis always comes to mind in a "nulligravid" middle aged woman who has heavy bleeding that occurs at menses and irregular intervals. The endometrial overgrowth (B and C) are distractors that are not related to irregular menses. Endometritis (E) is usually related to infection and there is no mention of that in the stem. Adenomyosis (A) would not show endometrial "abundant tissue" because they occur in the myometrium (although this would be on the differential of a woman with heavy menses and pain).

Hope that helps.

#2: I can confirm that D is incorrect, as per the convo below. I think B is right.

 

[SeahawksFan]

Please help me with this one:
a girl is brought to the physician for a well child examination. her normal developmet includes using a pincer grasp, finger feeding, standing while holding onto a table, playing peekaboo. which represent months of the px?
3
9
15
21
27

 

[strive2016]

Can anyone help me with this one...

49. A 12 yo boy is swimming in a mountain stream. he is immersed up to his neck n 60F water for 20 mins. which of the following sets of physiologic changes is most likely to occur in this boy?

Central Blood volume / ADH / ANP
A up/ up/ up
B up/up/down
C up/ down/ up
D up/ down/ down
E down/ up/ up
F down/ up/ down
G down/ down/ up
H down/ down/ down

Are we to assume the boy swallowed a ton of water???
I didnt understand what they were asking, so I put F at first which is incorrect.

Is A the corret answer?

C is correct
cold water will constrict your peripheral vessels (increase Central Volume) and this will lead to a higher volume coming into your atria, which is where your ANP is released due to increased stretch (ANP up). ANP will then oppose the release of ADH.

 

[mi91]

6 yo girl brought by her mother bcuz of 4 day hx of round shiny bumps in areas where she has eczema. Mother remembers similar bumps on a playmate 3 wks ago at a pool party. No other sx. Firm, smooth, umbilicated papules 2 to 4 mm in diameter. Which group?
Adeno
Flavi
Herpes
Paramyxo
Pox

45 yo m poorl controlled dm type 2, 1 m hx of low grade fever. Hemodialysis for esrd. Tem 37, hr 72, bp 144/92. Has a subclavian catheter. Lungs are clear no murmur. Two of the blood cx gram pos, nonhemolytic, catalase negative cocci in pairs and chains.
Causal organism?
E faecalis
Listeria
Aureus
S epidermidis
S pneumoniae

Thanks in advance.

 

[alyknight]

Please help me with this one:
a girl is brought to the physician for a well child examination. her normal developmet includes using a pincer grasp, finger feeding, standing while holding onto a table, playing peekaboo. which represent months of the px?
3
9
15
21
27

The baby is 9 months old. The motor characteristics for a baby that is 7-11 months is crawling, pulling him/herself up to stand, pincer grasp (using a thumb and forefiner grasp), transfers objects from hand to hand.

Motor characteristics for a 2-3 months old is lifting head when lying prone and later also lifts their shoulders
Motor characteristics from 12-15 months is walking unassisted.

 

[Avicenna_the_great]

1. C, very common cause of anemia is older person is GI blood loss. Different sizes of RBCs would give a wide red cell distribution width (RDW) which implies blood loss. The other answers do not make sense with the rest of the question stem. (A) would have pancytopenia, (B) would likely have a higher WBC and smear would have leukemia-looking cells, (D) would be severe microcytic anemia and would not be presenting now at age 72, and (E) no history to correlate with B12 deficiency/ no megaloblastic cells.

2. D, endometriosis always comes to mind in a "nulligravid" middle aged woman who has heavy bleeding that occurs at menses and irregular intervals. The endometrial overgrowth (B and C) are distractors that are not related to irregular menses. Endometritis (E) is usually related to infection and there is no mention of that in the stem. Adenomyosis (A) would not show endometrial "abundant tissue" because they occur in the myometrium (although this would be on the differential of a woman with heavy menses and pain).

Hope that helps.

Merci!

 

[chillaxbro]

A newborn delivered at 38 weeks' gestation weighs 1800 g (4 1b). Physical examination shows a petechial rash, microcephaly, and hepatosplenomegaly

Results of serologic testing for cytomegalovirus antibodies are shown:

Mother +IgG, -IgM for CMV
Newborn +IgG +IgM for CMV

Which of the following is the most likely explanation for the serologic findings in this newborn?
Newborn


A. Active transfer of maternal immunity to CMV
B. Continental CMV infection
C. False negative maternal serology
D. False positive neonatal serology
E passive transfer of maternal CMV IgG and IgM antibodies


Not A or E because IgM cant move across placenta... Not B because babies cant make IgM (I think)... So narrowed it down to C and D. I picked C and got it wrong. So answer must be D? Can anyone confirm and explain?

Is the positive IgM the false neonatal serology? Makes sense he has IgG from mom and doesnt make sense how he has IgM.

tl;dr what is the answer and why? And can anyone confirm if babies can make IgM? thanks!

 

[tvelocity514]

Not A or E because IgM cant move across placenta... Not B because babies cant make IgM (I think)... So narrowed it down to C and D. I picked C and got it wrong. So answer must be D? Can anyone confirm and explain?

Is the positive IgM the false neonatal serology? Makes sense he has IgG from mom and doesnt make sense how he has IgM.

tl;dr what is the answer and why? And can anyone confirm if babies can make IgM? thanks!

The baby won't get the infection unless the mom has an active infection (which she doesn't). He still got her Antibodies to it though since she had the infection in the past.

Also, babies begin to produce low levels of their own antibodies between 3 and 6 months before birth. These are IgM antibodies.

Levels of an infant's own IgG start to rise after birth, however don't reach a reasonable level until after the child is roughly 1 year old. Maternal antibodies start to tail off at around 3 months leaving a period where infants are particularly prone to getting infections.

 

[chillaxbro]

The baby won't get the infection unless the mom has an active infection (which she doesn't). He still got her Antibodies to it though since she had the infection in the past.

Also, babies begin to produce low levels of their own antibodies between 3 and 6 months before birth. These are IgM antibodies.

Levels of an infant's own IgG start to rise after birth, however don't reach a reasonable level until after the child is roughly 1 year old. Maternal antibodies start to tail off at around 3 months leaving a period where infants are particularly prone to getting infections.


Edit: also, what exactly is a continental cmv infection?

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Congenital infection **

So are you saying it can't be a congenital infection since mom doesnt have active infection? I have other people telling me the answer is B since you can indeed have IgM as a baby and therefore he has a congenital infection. I'm so confused Dx

 

[tvelocity514]

Congenital infection **

So are you saying it can't be a congenital infection since mom doesnt have active infection? I have other people telling me the answer is B since you can indeed have IgM as a baby and therefore he has a congenital infection. I'm so confused Dx

Ohhh then it's B bc mom passes a chronic infxn if it means congenital and not continental . I think this is the real right answer. I didn't realize you meant congenital and not continental. Because chronic infection is IgG positive and IgM negative. And you can make IgM as a baby


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[chillaxbro]

Ohhh then I think it's B bc mom passes a chronic infxn if it means congenital and not continental . I think this is the real right answer. I didn't realize you meant congenital and not continental. Because chronic infection is IgG positive and IgM negative. And you can make IgM as a baby


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Nice thanks

 

[a-Galactosidase A]

62 yr old man with alcohal liver ds develops massive ascites. infection ruled out . most appropriate diuretic treatment in addition to loop diuretics, includes which of the following drugs?

hydrochlorthiazide, acetazolamide, indapamide, mitolazone , spiranolactone


I know the answer is spironolactone.....but I didn't choose it......my thinking was it has the side effect of GYNECOMASTIA/ANTI-ANDROGEN (which makes his situation worse) so you wouldn't administer it.....is this just a bad question?

 

[livelongasap]

Please help with this Q:

58 y.o F brought to the ED because of 2 hours of SOB and chest pain that radiates to her back b/w the shoulder blades. RR 28/min. P.E. diaphoresis. An ECG is normal. Coronary angiography shows occlusion of the marginal branch of the LAD. Cath is done and a stent is placed. After the stend, her serum concentrations of myocardial creatine kinase (CK-MB) and troponin I are increased.Which of the following mechanisms best explain these laboratory findings?

A) Cell shrinkage
B) Formation of apoptotic bodies
C) Liquefactive necrosis of the myocardium
D) Membrane lipid peroxidation
E) Protease inactiviation by cytoplasmic free calcium ions

I assumed that the rise in cardiac enzymes was due to myocyte death and apoptosis (B) but that is not correct. Is it asking about reperfusion injury (D)?

Does anyone know the answer to this? there's so many pages in the thread I never found it

 

[a-Galactosidase A]

Does anyone know the answer to this? there's so many pages in the thread I never found it

Answer is D. Membrane lipid peroxidation. Its reperfusion injury due to the stenting.

 

[hybrid5]

A 27-year-old woman is brought to the emergency department 30minutes after she was ejected through the windshield during a motor vehicle collision. She was the unrestrained front-seat passenger. Physical examination shows marked edema and tenderness of the jaw. A Panorex x-ray of the mouth is shown. Which of the following additional structures is most likely injured by this abnormality? IMAGE answer: inferior alveolar nerve

 

[ucpatrick]

)A 60 y.o woman with tenderness to palpation of the rt ankle joint. Analysis of joint fluid aspirate shows negatively birefringent crystals. Sensation to pinprick is decreased in the feet. The patient is at increased risk for with of the following complications of the underlying process causing the joint findings?

a)cholelithiasis
b)nephrolithiasis
c)osteoarthritis - wrong
d)osteoporosis
e)pathologic fracture

Pls someone help me with this....thanks

 

[TBV]

)A 60 y.o woman with tenderness to palpation of the rt ankle joint. Analysis of joint fluid aspirate shows negatively birefringent crystals. Sensation to pinprick is decreased in the feet. The patient is at increased risk for with of the following complications of the underlying process causing the joint findings?

a)cholelithiasis
b)nephrolithiasis
c)osteoarthritis - wrong
d)osteoporosis
e)pathologic fracture

Pls someone help me with this....thanks

B- uric acid crystals- uric acid stones?

 

[aghmah88]

I got 53% incorrect - 390 (205 scaled score)

i got the same score and im freaking out since my exam is in a few weeks. what did you do to improve your score?

 

[Chubster]

62 yr old man with alcohal liver ds develops massive ascites. infection ruled out . most appropriate diuretic treatment in addition to loop diuretics, includes which of the following drugs?

hydrochlorthiazide, acetazolamide, indapamide, mitolazone , spiranolactone


I know the answer is spironolactone.....but I didn't choose it......my thinking was it has the side effect of GYNECOMASTIA/ANTI-ANDROGEN (which makes his situation worse) so you wouldn't administer it.....is this just a bad question?

I had the same thinking about gynecomastia. Perhaps it is because spironolactone is the only diuretic option that is K+ sparing. In liver disease there is venous pooling -->decreased RBF --> that can lead to secondary hyperaldosteronism, causing a patient to lose more potassium. Thus it may be beneficial to give this patient a potassium sparing diuretic.

 

[midwestm2]

Hi guys I'm sorry to be like this but I had a quick question too - does anyone know which cells are initially involved in the fibrosis process for someone exposed to asbestos? I put alveolar macrophages and I didn't pay to see which questions I got wrong, and am having trouble finding the right answer. Please let me know if you know that you got it right/what the answer is/any explanation. Thanks!

 

[Chubster]

Hi guys I'm sorry to be like this but I had a quick question too - does anyone know which cells are initially involved in the fibrosis process for someone exposed to asbestos? I put alveolar macrophages and I didn't pay to see which questions I got wrong, and am having trouble finding the right answer. Please let me know if you know that you got it right/what the answer is/any explanation. Thanks!

Yeah I think it was alveolar macrophages. In Pathoma (p 92) it says that pneumoconioses are macrophage mediated. "alveolar macrophages engulf foreign particles and induce fibrosis". I remember this because it involves exposure to small particles the questions on Uworld about clearing foreign particles mention that small particles are cleared by alveolar macrophages since they can by pass the terminal bronchioles.

 

[jqueb29]

Hi guys I'm sorry to be like this but I had a quick question too - does anyone know which cells are initially involved in the fibrosis process for someone exposed to asbestos? I put alveolar macrophages and I didn't pay to see which questions I got wrong, and am having trouble finding the right answer. Please let me know if you know that you got it right/what the answer is/any explanation. Thanks!

Yep, definitely alveolar macrophages. With help from Pathoma, I think of it as basically they engulf the pneumoconiogenic particles and are like "omg what is this idk what to do with this" and just panic and initiate a bunch of fibrosis. Very unscientific but for some reason the image of a panicking macrophage makes it stick in my head

 

[midwestm2]

^ I think that was my thought process too... subconsciously...

Thanks to both of you guys for helping to clear that up (macrophage pun intended)

 

[doctorhopefully]

a

 

[recycledpaper]

Conjugation with a protein allows for a better immune response (a T-dependent response). If it were just the capsule, it would elicit a T-independent response and wouldn't be as strong. Hib is classic for a conjugated vaccine. If you use SketchyMicro, it's the sign where the sugar strawberries are "dipped" for $2.18. The dipped part tells you that it uses a diptheria protein for conjugation (not to be confused with the diptheria vaccine, which is capable of eliciting a T-dependent on its own because it's a protein antigen).

The left atrium is the most posterior structure of the heart. So if you have an enlargement that is compressing the esophagus, it makes sense that the most posterior structure is doing it. Just to add, don't forget that DCM is a dilation of all four chambers of the heart.

 

[doctorhopefully]

Conjugation with a protein allows for a better immune response (a T-dependent response). If it were just the capsule, it would elicit a T-independent response and wouldn't be as strong. Hib is classic for a conjugated vaccine. If you use SketchyMicro, it's the sign where the sugar strawberries are "dipped" for $2.18. The dipped part tells you that it uses a diptheria protein for conjugation (not to be confused with the diptheria vaccine, which is capable of eliciting a T-dependent on its own because it's a protein antigen).

The left atrium is the most posterior structure of the heart. So if you have an enlargement that is compressing the esophagus, it makes sense that the most posterior structure is doing it. Just to add, don't forget that DCM is a dilation of all four chambers of the heart.

Thank you!!!

 

[doctorhopefully]

quote

 

[zhopv10]

It is A with an LDL of 900 this pt is probably young and almost certainly a homozygote for the LDL receptor knockout. E would be true for a heterozygote who would have high LDL but not outrageously high necessarily. Also B can actually be involved in familial hypercholesterolemia but the phenotype is usually less severe.


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[doctorhopefully]

quote

 

[dorster]

.

 

[doctorhopefully]

(deleted)

 

[zhopv10]

l3-4 (those dermatomes are described by where the pain is). S4-5 is the butt, l1-2 is inguinal more, t 10 is belly button s1-2 is like the heel and popliteal areas


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[yoyohomieg5432]

1) for the question about the diaphragmatic hernia in the little kid, why does the nasogastric tube go to the left but the mediastinum go to the right? wouldn't esophagus shift right with the mediastinum, since it's in the mediastinum??


20. A 28-year-old man is brought to the emergency department 30 minutes after the sudden onset of shortness of breath. He has a 3-year history of cocaine abuse. His temperature is 38.1°C (100.6°F), pulse is 100/min, and blood pressure is150/45 mm Hg. Physical examination shows diminished pulses in the left upper extremity. Crackles are heard over all lung fields. A grade 2/6 diastolic murmur is heard best at the left sternal border. A chest x-ray shows a widened aortic arch. Which of the following is the most likely diagnosis?
A
) Atherosclerotic aneurysm
B
) Dissecting aneurysm
C
) Mycotic aneurysm
D
) Pseudoaneurysm
E
) Saccular aneurysm
---answer was dissecting aneurysm. is that the same thing as aortic dissection? how can we tell that apart from the other options? There was no reported "pain radiating to the back" which would be a hallmark. also, what's causing the diminished pulse in the left arm? and the lung crackles


4) . . A 40-year-old woman comes to the physician because of a 1-year history of episodes of crampy abdominal pain, intermittent diarrhea, and rectal bleeding with passage of mucus. She is 173 cm (5 ft 8 in) tall and weighs 55 kg (120 lb); BMI is18 kg/m2. Abdominal examination shows diffuse tenderness with no rebound tenderness. Sigmoidoscopy shows a few diffuse ulcers. Which of the following is the most appropriate initial pharmacotherapy for this patient?
Answer is sulfasalazine. I suspect this is UC but the part that kind of threw me off was "diffuse ulcers" isn't UC usually "continuous" ulceration? and diffuse is more crohns

5. The 83 year old man bedridden and confused with BP of 85/50. his BP doenst change after IV infusion of saline. Temp is 96

I think someone said the answer was early septic shock, but why? He has no fever.. and wouldn't saline still help the BP?

6. Is there any consensus on the one with the cytochrome p450 3D64 alleles for tamoxifen and what was the chance the sister had the same alleles? How are we supposed to know what the parents genotype was in order to do this one?

7. the kid with hypercholesterolemia.. why is B wrong?

also, I thought that the LDL receptor was mainly present on the peripheral cells since LDL's job is to deliver cholesterol to the periphery. why does the correct answer say that the LDL receptor is on the liver?

thank you!

 

[yoyohomieg5432]

sorry, one last questions.. what's up with that HIV one... there are apparently several strains of HIV? I'm assuming the anti-HIV drugs work just the same for both, right? How do the strains differ

there was one with a kid with some kind of vein enlargement in his anus.. what was the diagnosis on that one? the answer was inferior rectal vein

for the one about the mesenteric venous thrombosis, was it simply his cirrhosis/HCC causing portal backup and then one of the veins ruptured? or the blue appearance was just from blood backup?

 

[DerpStore]

sorry, one last questions.. what's up with that HIV one... there are apparently several strains of HIV? I'm assuming the anti-HIV drugs work just the same for both, right? How do the strains differ

there was one with a kid with some kind of vein enlargement in his anus.. what was the diagnosis on that one? the answer was inferior rectal vein

for the one about the mesenteric venous thrombosis, was it simply his cirrhosis/HCC causing portal backup and then one of the veins ruptured? or the blue appearance was just from blood backup?

HIV-2 is a much less common form of HIV thats pretty much only found in Africa. Its generally considered less pathogenic. Serology studies are performed first to look for p24 (capsid) and will be positive for both HIV-1 and 2 which is what was seen in the question stem. NAT for viral RNA is designed to be more specific (primers must bind to regions of HIV-1 not found in HIV-2) and can differentiate between strains. But yeah, the guy clearly had HIV, all you really needed to know to get that right is that there are two main strains, and saying he's from West Africa seals the deal.

I don't remember the other questions as much. Second one sounds like hemorrhoids. Painful=inferior rectal vein bc it is somatically innervated by the internal pudendal as it is below the pectinate line. Third one- you are correct its secondary to the portal hypertension. Sorry don't remember more of the question.

 

[DerpStore]

1) for the question about the diaphragmatic hernia in the little kid, why does the nasogastric tube go to the left but the mediastinum go to the right? wouldn't esophagus shift right with the mediastinum, since it's in the mediastinum??


20. A 28-year-old man is brought to the emergency department 30 minutes after the sudden onset of shortness of breath. He has a 3-year history of cocaine abuse. His temperature is 38.1°C (100.6°F), pulse is 100/min, and blood pressure is150/45 mm Hg. Physical examination shows diminished pulses in the left upper extremity. Crackles are heard over all lung fields. A grade 2/6 diastolic murmur is heard best at the left sternal border. A chest x-ray shows a widened aortic arch. Which of the following is the most likely diagnosis?
A
) Atherosclerotic aneurysm
B
) Dissecting aneurysm
C
) Mycotic aneurysm
D
) Pseudoaneurysm
E
) Saccular aneurysm
---answer was dissecting aneurysm. is that the same thing as aortic dissection? how can we tell that apart from the other options? There was no reported "pain radiating to the back" which would be a hallmark. also, what's causing the diminished pulse in the left arm? and the lung crackles


4) . . A 40-year-old woman comes to the physician because of a 1-year history of episodes of crampy abdominal pain, intermittent diarrhea, and rectal bleeding with passage of mucus. She is 173 cm (5 ft 8 in) tall and weighs 55 kg (120 lb); BMI is18 kg/m2. Abdominal examination shows diffuse tenderness with no rebound tenderness. Sigmoidoscopy shows a few diffuse ulcers. Which of the following is the most appropriate initial pharmacotherapy for this patient?
Answer is sulfasalazine. I suspect this is UC but the part that kind of threw me off was "diffuse ulcers" isn't UC usually "continuous" ulceration? and diffuse is more crohns

5. The 83 year old man bedridden and confused with BP of 85/50. his BP doenst change after IV infusion of saline. Temp is 96

I think someone said the answer was early septic shock, but why? He has no fever.. and wouldn't saline still help the BP?

6. Is there any consensus on the one with the cytochrome p450 3D64 alleles for tamoxifen and what was the chance the sister had the same alleles? How are we supposed to know what the parents genotype was in order to do this one?

7. the kid with hypercholesterolemia.. why is B wrong?

also, I thought that the LDL receptor was mainly present on the peripheral cells since LDL's job is to deliver cholesterol to the periphery. why does the correct answer say that the LDL receptor is on the liver?

thank you!

1. The stomach is where the left lung should be, compressing the esophagus. The tube is in the stomach, but the stomach is in the left chest, compressing the mediastinum to the right.

2. Cocaine+widened mediastinum+diminished pulses in the left upper extremities=dissection.
3. Sulfasalazine is used to treat colonic Crohns as well as UC. As far as I remember the other ulcer treating drugs were for peptic ulcers (bismuth or whatever isn't going to do anything in the colon for example)
4. Old people don't always get fevers when septic. Sepsis is high output cardiac failure- fluids won't be as helpful bc of the capillary leak- all the fluid is getting out of the vasculature and not exerting a pressure.
5. I thought this was a stupid question. So her parents are either both homozygotes, both heterozygotes, or one heterozygote, one homozygote for the 3d64 allele. I think you have to assume that the allele is uncommon or else tamoxifen wouldn't be as useful. So fitting with this reasonable assumption, say her parents are both heterozygotes and this gets you to the correct answer. Somebody please correct me if there is some better logic for this!
6. First off LDL receptor deficiencies are much more common. Second (not 100% confident) B100 is involved with LDL and VLDL, but the stem states it is a specific increase in LDL. So the answer is A. Most LDL is actually taken up by the liver (I think around 70%) for storage. Most cholesterol meds (including statins) MOA is ultimately aimed at increasing LDL receptor density in the liver.

 

[yoyohomieg5432]

1. The stomach is where the left lung should be, compressing the esophagus. The tube is in the stomach, but the stomach is in the left chest, compressing the mediastinum to the right.

2. Cocaine+widened mediastinum+diminished pulses in the left upper extremities=dissection.
3. Sulfasalazine is used to treat colonic Crohns as well as UC. As far as I remember the other ulcer treating drugs were for peptic ulcers (bismuth or whatever isn't going to do anything in the colon for example)
4. Old people don't always get fevers when septic. Sepsis is high output cardiac failure- fluids won't be as helpful bc of the capillary leak- all the fluid is getting out of the vasculature and not exerting a pressure.
5. I thought this was a stupid question. So her parents are either both homozygotes, both heterozygotes, or one heterozygote, one homozygote for the 3d64 allele. I think you have to assume that the allele is uncommon or else tamoxifen wouldn't be as useful. So fitting with this reasonable assumption, say her parents are both heterozygotes and this gets you to the correct answer. Somebody please correct me if there is some better logic for this!
6. First off LDL receptor deficiencies are much more common. Second (not 100% confident) B100 is involved with LDL and VLDL, but the stem states it is a specific increase in LDL. So the answer is A. Most LDL is actually taken up by the liver (I think around 70%) for storage. Most cholesterol meds (including statins) MOA is ultimately aimed at increasing LDL receptor density in the liver.

thank you for the responses. i'm still a little confused about the first one. I can udnerstand that the stomach would go to the left, but I'm confused at how the mediastinum can go to the right because the esophagus is within the mediastinum, so if the nasogastric tube goes from the esophagus to the stomach which is to the left, I would think the mediastinum would also have to be getting pulled that way as well. I don't see how the esophagus is simultaneously with the mediastinum on the right, but also on the left in order to feed into the stomach (unless there's some cool quantum physics going on!lol)

 

[recycledpaper]

The stomach is on the left, so it makes sense the NG tube is also on the left. The size of the stomach is what causes the mediastinal shifting to the right.

 

[TheShaker]

for the one about the mesenteric venous thrombosis, was it simply his cirrhosis/HCC causing portal backup and then one of the veins ruptured? or the blue appearance was just from blood backup?

I don't remember this question exactly but didn't he have a thrombus in the vein? I assumed it worked kinda like a DVT, with the portal HTN causing endothelial damage and stasis in that vein --> 2/3 of virchow's triad?

 

[MackandBlues]

for the one about the mesenteric venous thrombosis, was it simply his cirrhosis/HCC causing portal backup and then one of the veins ruptured? or the blue appearance was just from blood backup?

it actually thrombosed so the blood clot is causing the severe pain and bluish color

 

[jpwsurf21]

Question regarding: "Serum - Na-143, K-3.2, CL-101, HCO3-11, Arterial blood gas analysis- PH-7,28, PCo2-23, PO2-98, what is the acid-base status of the pt?"
I get that there's a metabolic acidosis with appropriate respiratory compensation, but can anyone explain why this isn't a mixed metabolic acidosis and metabolic alkalosis?
When you check the delta delta, you get Delta AG = 31 and Delta Bicarb = 13 so the delta delta ratio is greater than 2. Doesn't that mean there's a metabolic alkalosis? Or is this not a case where you should check delta delta?

 

[Adjet]

Question regarding: "Serum - Na-143, K-3.2, CL-101, HCO3-11, Arterial blood gas analysis- PH-7,28, PCo2-23, PO2-98, what is the acid-base status of the pt?"
I get that there's a metabolic acidosis with appropriate respiratory compensation, but can anyone explain why this isn't a mixed metabolic acidosis and metabolic alkalosis?
When you check the delta delta, you get Delta AG = 31 and Delta Bicarb = 13 so the delta delta ratio is greater than 2. Doesn't that mean there's a metabolic alkalosis? Or is this not a case where you should check delta delta?

I'm not too sure about the whole delta delta ratio, but I think this is a situation where they would like you to use Winter's formula to calculate the appropriate compensation:
PCO2 = 1.5[HCO3-] + 8 +/- 2 = 24.5 +/- 2. I don't think we need to know the compensation for other metabolic disturbances, but I would know this formula for metabolic acidosis

If they wanted the answer to be a mixed metabolic disturbance, they would probably make the discrepancy significantly greater than the margin of error so as not to not confuse anyone

 

[jpwsurf21]

I'm not too sure about the whole delta delta ratio, but I think this is a situation where they would like you to use Winter's formula to calculate the appropriate compensation:
PCO2 = 1.5[HCO3-] + 8 +/- 2 = 24.5 +/- 2. I don't think we need to know the compensation for other metabolic disturbances, but I would know this formula for metabolic acidosis

If they wanted the answer to be a mixed metabolic disturbance, they would probably make the discrepancy significantly greater than the margin of error so as not to not confuse anyone

Thanks for the response! I actually realized I made a dumb calculation mistake. The delta delta is actually just 19/13 so it's less than two aka no mixed disorder. haha that was driving me crazy

 

[aduharar]

as to what causes full resolution after pneumonia,i chose metaplasia of mesenchymal cells ans got it wrong.sorry. maybe the answer is maintenace of structural integrity of the BM??

metaplasia is a strict definition. MSC of mesenchymal stem cells is a type of differentiation.

 

[BR20]

a 68 yo woman w/ recent onset DM2 & poorly controlled HTN despite HTZ tx. BP 150/96. Serum glucose 130. + Proteinuria. What other med should added?
A. Amlodipine
B. Clonidine
C. Hydralazine
D. Lisinopril (correct)
E. Triamterene

Is this one of those "which med has been shown to decrease mortality" questions, or can someone please explain this to me? Thanks!