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NBME 13 discussion

Discussion in 'Step I' started by ijn, 03.09.12.

  1. Morsetlis

    Morsetlis SGU MS-4

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    SDN Members don't see this ad. (About Ads)
    Lymphedema is due to blockage of the flow of lymph due to a resectioned lymph node.

    The general flow of fluid is capillaries <-> interstitial <-> lymph. With a blockage of the lymph drainage, compression will help push lymph back into the interstitial, and then capillaries, where it can drain into other lymphatic systems that are thorough.

    Diuretics act at the capillaries level and are therefore less effect than compression, not to mention that a person with lymphedema can be normovolemic and will then develop hypovolemia if you give them a diuretic.

    Passive movement / exercise actually do treat lymphedema, but of course not as well as compression sleeves. If passive movement /exercise treated it entirely, it wouldn't be a problem in the first place.
  2. Drteeth21

    Drteeth21

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    Can someone explain to me this answer??

    A 19 year old woman comes to the physician because of increasingly severe pain in the right hip during the past month. She has a 4 year old history of refractory inflammatory bowel disease with arthritis in the hands treated with corticosteroids for the past 2 years. An x ray of the pelvis shows collapse of the superior half of the rigth femoral head with preservation of the articular cartilage. The left hip appears normal. Which of the following is the most likely cause of the hip abnormality?
    A) ankylosing Spondylitis
    B) aseptic necrosis
    C) gouty arthritis
    D) multiple myeloma
    E) septic arthritis

    I put Ankylosing spondylitis because of the HLA association? anyone know what the right answer is??
  3. frankyazz

    frankyazz LECOM '14

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    chronic corticosteroids = bad for bones = aseptic necrosis
  4. sanityonleave

    sanityonleave Adrenaline Junkie

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    b) aseptic necrosis (aka avascular necrosis)

    The x-ray presentation of collapse of the femoral head with preservation of the cartilage doesn't fit with AS. AS usually starts with the sacroiliac joint, though it can progress to the hip joint -- in the event that happens, it should lead to inflammation / pain / fusion (a more inflammatory picture with cartilage disruption and inflammation).

    Collapse of the top half of the head without cartilaginous involvement describes a noninflammatory process -- aseptic (aka avascular) necrosis. This is likely due to her long-term corticosteroid use which is a very significant risk factor.

    Even if it didn't necessarily include the x-ray findings and just said she had hip pain, I'd still point to necrosis from the steroids before AS (common things being common, after all) -- but with the x-ray findings that's a slam dunk.
  5. Drteeth21

    Drteeth21

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    oh good call guys. spot on that was dumb on my part.

    Another Q

    Can someone explain this
    A previously healthy 40 year old man is brought to the emergency dept 1 hour after hte sudden onset of svre pain in his left leg while playing tennis. he has ruptured Achillese tendon and undergoes operative repair and long leg cast immobilization. six months later his calf is atrophied. whats tha most liklely cause of the decrease?
    a) decreased glycogen synthesis
    B) decreased myosin light chain phosphatase activity (wrong)
    C) increased phosphatidyl degradation
    D Increased protein degradation
    E mito damage
    E necrosis of muscle fibers
    I saw myosin and just picked it but that operates smooth muscle so that was a dumb choice haha

    and can someone explain WHY this answer is right
    18 year old man has had temps, sore throat, cervical lymop hnode enlargment for 8 days. Latex agglutinatin pos for EBV. atypical cells with abundant lacey cytoplasm in the periph blood smear are most likely derived from which of the following cell types?
    A) B cells (wrong)
    B) basophils
    C) neutrophils
    D) plasma cells
    E) T lymphocytes (why is this right>!)

    9/10 times im putting B cells when I see EBV i have no idea why t cells would be right
  6. ijn

    ijn

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    If you don't use your muscles then they atrophy by breaking down the myofibrils into their constitutive proteins. That protein is then shuttled into urea and gluconeogenesis.

    Atypical (reactive) lymphocytes are T-cells. EBV does infect B-cells. I don't know why the T-cells become larger with certain viral infections.
  7. Drteeth21

    Drteeth21

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    ok cool thanks! so the first one should be protein degradation. how could you tel that theyre talking abut T cells over B cells though. B cells in mono would be atypical as well wouldnt they?
  8. frankyazz

    frankyazz LECOM '14

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    EBV infects B cells. T cells kills other cells infected by viruses. The atypical lymphocyte is a T-cell reacting to the infected B cell. "Atypical" is not just a general term... it used to go by "Downey cell" and is supposed to represent the T-cell.
  9. Drteeth21

    Drteeth21

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    oh wow great explanation. thanks!!
  10. netminder

    netminder

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    Corticosteroids inhibit osteoblast proliferation and differentiation directly. Glucocorticoids also increase bone resorption by decreasing secretion of androgens and estrogens, mediated primarily by inhibition of gonadotropin secretion. Also, glucocorticoids stimulate osteoclast proliferation by suppressing synthesis of osteoprotegerin, an inhibitor of osteoclast differentiation from the macrophage lineage, and by stimulating production of RANK, which is necessary for osteoclastogenesis. Glucocorticoids also induced stimulation of synthesis of RANKL by preosteoblasts/stromal cells, which supports osteoclast differentiation and net bone resorption.

    Long answer. I'm thinking in this case with the osteonecrosis of the hip, the increase in bone resorption by decreasing secretion of sex steroids (along with the other factors above coming into play) probably contributes most significantly to inability of the bone (especially on the weight-bearing surface, as described in the question stem) to remodel following repetitive stress --> stress fractures --> don't heal on corticosteroids --> vicious cycle.

    Butt-nasty test, this was.
  11. sunyD

    sunyD

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    Okay, am I missing something or is this one of those wtf questions?

    A 55 yo man with hepatic encephalopathy is brought to the physician because of confusion and increased lethargy during the past 24 hrs. He has a history of cirrhosis of the liver caused by hepatitis C. He is easily a rousable despite the lethargy. His temp is 37. Physical examination shows scleral icterus, asterixis, a protuberant abdomen, and ascites. Test of the stool for occult blood is negative. Administration of which of the following drugs is most likely to improve this patient's mental status.

    A. Bisacodyl
    B. Docusate
    C. Lactulose
    D. Octreotide
    E. Omeprazole
    F. Sucralfate
    G. Ursodiol
  12. ijn

    ijn

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    Using lactulose to treat hepatic encephalopathy is pretty high yield. Definitely not a WTF question.
  13. sunyD

    sunyD

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    Good thing I asked then. Thanks.

    I found it on page 4 of kaplan...I haven't checked that section in months since its pharmacokinetics...
  14. amsfromanams

    amsfromanams

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    Hey all, here's a couple questions that I couldn't find a good answer for:

    Section 1, #39
    A 25 yo with cystic fibrosis comes in with a 3-day history of fever, cough, shortness of breath. His temp is 100.4 F and RR is 32. Bilateral crackles and rhonchi are heard. A culture grows aerobic, oxidase positive, gram negative rods that form slimy colonies and produce pyocyanin. It does not ferment lactose, treatment with multiple antibiotics hasn't worked. What is the best explanation for the persistent colonization of this patient?
    A: bacteriophage superinfection
    B: biofilm formation in the lower respiratory tract
    C: overgrowth of acapsular strains
    D: pyocyanin synthesis
    E: synthesis of exotoxin A (wrong)

    He's got pseudomonas, is it the biofilm?

    Section 3, #6
    A previously healthy 32 yo man comes in to the ER with a 1 day history of intermittent flashing spots/blurred vision, vomiting, confusions, and difficulty walking. He is painter and yesterday cleaned up a paint thinner spill. He has dilated pupils with hyperemia of the optic disc and retinal edema. He has tachypnea and an anion gap metabolic acidosis. The most appropriate therapy will inhibit the activity of which of the following?
    A: alcohol dehydrogenase
    B: aldehyde dehydrogenase
    C: formaldehyde dehydrogenase (total guess, wrong)
    D: lactate dehydrogenase
    E: pyruvate dehydrogenase

    Section 3, #36
    A 54 yo woman with a 5 day history of severe mid-back pain. Exam shows point tenderness over T6 vertebrae. Serum calcium is 13.4 mg/dL, urinalysis shows Bence Jones proteins. What is the most likely cause of her hypercalcemia?
    A: excessive PTH production
    B: excessive PTHrP production
    C: increased fractional calcium GI absorption
    D: local IL-1 and tumor necrosis factor effects
    E: unregulated 1,25 dihydroxycholecalciferol production (wrong)

    So she's got multiple myeloma, what's the mechanism of hypercalcemia in MM? I thought it had something to do with elevated vitamin D.
  15. ijn

    ijn

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    Hypercalcemia in sarcoidoisis is due to elevated 1,25 vitamin D. Multiple myeloma and other lytic bone cancers are due to increased IL-1/TNF alpha. Remember the other name for IL-1 is osteoclast activating factor.

    I think the guy was poisoned by methanol. You should give ethanol or fompeizole to inhibit alcohol dehydrogenase to prevent the buildup of formaldehyde and subsequent formic acid.

    The decreased mucociliary clearance in CF promotes biofilm formation and persistent reinfection. Exotoxin would explain any acute effects of the pseudomonas infection, but doesn't explain chronic colonization. Anytime you hear the words colonization in association with bacteria then think biofilm.
  16. Azipropofol

    Azipropofol

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    Not sure if anyone agrees but I think 13 was way more of a ball breaker than 7. Many "are you a good test taker" questions with many "distractor in stem" questions in between. Just my 2c.
  17. VisionaryTics

    VisionaryTics Señor Member

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    I took it yesterday, and that was my thought. All of the wtf questions were actually just simple concepts if you could pick apart the stem. I thought it was pretty straightforward as long as you didn't get hung up on their sttempts to confuse you.
  18. netminder

    netminder

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    Azipropofol, I agree -- particularly with your assessment of the ball-breaking component. I didn't take NBME 7, but I did find NBME 13 to be moderately irritating.
  19. tele turnin

    tele turnin

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    37.
    A 5-year-old girl is brought to the physician because of listlessness, fatigue, and dull pain in the right upper quadrant of the abdomen. Her height and weight are below the 25th percentile. Laboratory findings indicate that the content of her &#946;-globin chain is 15% to 20% of normal. Sequencing of the &#946;-globin gene shows a point mutation in a sequence 3&#8242; to the coding region in which AATAAA is converted to AACAAA. Consequently, the amount of mRNA for &#946;-globin is decreased to 10% of normal. Which of the following functions in mRNA synthesis and processing is most likely encoded by the sequence AATAAA?

    a) capping with GTP
    b) cleavage and polyadenlyation
    c) silencing the promoter
    d) splicing of the initial mRNA transcript in the nucleus
    e) transport of the mRNA out of the nucleus


  20. VisionaryTics

    VisionaryTics Señor Member

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    B. It's the polyadenylation sequence. Pg. 75 in FA.
  21. mycoplasmajune

    mycoplasmajune

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    need help in these

    1 - 8 years old boy , 1 year of and self mutilation , his male cousin has the same , biting finger , spasticity ???


    2- role of tretinoin in collagen synthesis ????
  22. VisionaryTics

    VisionaryTics Señor Member

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    1-Lesch-Nyhan
    2-Binds to nuclear receptors -> regulation of transcription
  23. mycoplasmajune

    mycoplasmajune

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    thanks
    for 1 it was bad to miss it !!!
  24. EbolaScola

    EbolaScola

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    Could you explain why the answer is heroin? Thanks!
  25. adele87

    adele87

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    The time course and the symptoms of uncontrolled crying, constant sucking, irritability and hyperactive reflexes fit the picture of neonatal abstinence syndrome (from opioids). You can read more about it on uptodate:
    http://www.uptodate.com/contents/neonatal-opioid-withdrawal
  26. EbolaScola

    EbolaScola

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    Unfortunately, I don't have access to UTD, but thanks!
  27. missmedschool

    missmedschool MS3

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    This tripped me up because I don't think I've ever been asked to identify the postcentral gyrus on the RIGHT side of the brain :confused: ugh I guess I'm just used to it being a nice pretty contiguous line like on the left side. That or the placement of "B" seemed to separate the upper half of the brain from the lower half so I assumed they couldn't really be connected. Sigh. :bang:
  28. missmedschool

    missmedschool MS3

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    If anyone can help me with the below questions I would be too happy. Thanks!

    1. The peptidyl transferase question. Was the answer "attachment of amino acids to tRNA"? I got tripped up by the whole 60S 80S stuff

    2. A 33 year old woman who is right-handed is brought to the physician because of a 3-day history of progressive weakness and numbness of her arms and legs. Neurologic examination shows proximal and distal weakness of the upper and lower extremities. There is areflexia. Sensation to vibration and joint position is decreased in the fingers and toes. Nerve conduction studies show a slow conduction velocity in the median, ulnar, peroneal, and tibial nerves. These electrophysiologic findings most likely indicate impaired function of which of the following ion channels?

    a) neurotransmitter-gated Ca+2 channels
    b) neurotransmitter-gated Na+ channels
    c) neurotransmitter-gated K+ channels (WRONG )
    d) Voltage-gated Ca+2 channels
    e) Voltage-gated Na+ channels
    f) Voltage-gated K+ channels

    Could someone please explain the pathophys behind this?

    3. A 46 year old man receives diagnosis of SCC of the esophagus. A barium swallow is shown Esophagectomy at the region (there was an accompanying image) is most likely to involve ligation of arterial branches of which of the following vessels?
    a. aorta
    b. internal thoracic artery
    c. pulmonary arteries
    d. SMA
    e. thyrocervical trunk

    4. In order to determine risk factors for death from coronary artery dz persons aged 30 yrs and older are studied in a community. Every 2 yrs for a total of 10 yrs BP, cholesterol, smoking status is assessed along with deaths from CAD Persons with increased BP are compared to those with normal BP to determine which group has greater mortality from CAD. Which of the following best explains this study?
    a. case control
    b. case series
    c. cross sectional
    d. ecologic
    e. observational cohort
    f. randomized clinical trial

    Would appreciate if someone explained this one to me--> I was stuck between observational cohort and cross sectional

    5. There was one about an Asian woman who took acetaminophen and alcohol together, she had acetiminophen toxicity and it wanted to know what was alcohol's effect. The answer choices were
    a. decreased generation of nacetyl p benzoquinoeimine
    b. increased glucoronidation
    c. increased hepatic glutathione stores
    d. increased sulfation
    e. induction of cp450

    6. One showed a tracing of a skeletal mm preparation and it asked which one had the highest amount of calicum sequestration?

    7. A 60 year old woman with 2 day history of flank pain and pain with urination. She has HTN, recurrent UTIs, hypothyroidism ... normal temperature ... urinalysis 3+ blood, 1+ leukocytes, few bacteria. Imaging shows large calculus filling the entire right renal pelvis. What is the calculus most lkely composed of?

    a. calcium oxalate
    b. cystine
    c. struvite
    d. uric acid

    I put calcium oxalate because she had no fever, so I thought struvite couldn't be right, but ... yeah. It was wrong. Explanation on this please?
  29. VisionaryTics

    VisionaryTics Señor Member

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    herp
    Last edited: 06.02.12
  30. ijn

    ijn

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    1. Aminoacyl-tRNA synthetase attaches amino acids to tRNA. Peptidyl transferase forms linkages between amino acids on the growing peptide chain.

    2. Voltage gated sodium channels. It was honestly a guess when I originally took it. I know the answer is a voltage gated channel because condunction velocity is slower, but I'm not sure how they decided it couldn't be potassium. I guess if you had a potassium channel defect they'd be talking about how movement on repeated stimulation was imparied b/c of slow repolarization. Or maybe they'd be talking about some sort of long QT symptoms.

    3. The aorta directly supplies blood to the esophagus.

    4. Observational cohort

    5. Chronic alcoholism induces cytochrome P450, therefore increasing the rate of glutathione depletion by acetaminophen => increased hepatotoxicity

    6. Edit: oops, read it wrong. Definitely the one with the most peaks and valleys. A.

    7. Struvite stones can get large enough to fill the whole renal pelvis. Calcium oxalate stones don't get that large and aren't associated with UTIs.

    [​IMG]
  31. Drteeth21

    Drteeth21

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    hey everyone! so my test is on wednesday and I'm totally freaking out. anyone hear anything about it this past month? I've taken pretty much all the nbmes at this point 13 last week and just took 12 and shooting for a 250. ive been in the 240s for 12 and 13.
    anyone know anything?!
  32. VisionaryTics

    VisionaryTics Señor Member

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    I know lots of things.
  33. missmedschool

    missmedschool MS3

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    OK so for the peptidyl transferase one the answer is "establishment of covalent bonding between amino acids" ... ?

    & thanks VisionaryTics and ijn! :D
    Last edited: 06.02.12
  34. Drteeth21

    Drteeth21

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    well that helps visionary haha
  35. Azipropofol

    Azipropofol

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    The little girl with periorbital edema who was peeing protein after a URI for the past 2 weeks. No RBC or WBC in urine. They were selling PSGN hard and I know the answer was loss of neg charge of basement membrane.

    My question: if PSGN makes you pee protein from the IC damage to the BM, why isnt it considered a nephrotic? (philosophic velociraptor pose)

    Also dumb question: when they say "+10" what does this mean? Is it just an absolute number or does it have units? If so What units is it in?
  36. frankyazz

    frankyazz LECOM '14

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    Because loss of negative charge isn't PSGN, its minimal change disease, which IS a nephrotic syndrome. Plus there were no RBC so you should know it wasn't a nephritic syndrome.
  37. sunyD

    sunyD

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    Sorry was looking at page 1...
    Last edited: 06.03.12
  38. takethat12

    takethat12

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    5.
    A 77-year-old woman dies in the hospital after a long illness. Her vertebral column, obtained at autopsy, is shown in the photograph. The process shown is most likely associated with an increase in which of the following?

    A) Calcium
    B) Estrogen
    C) Interleukin-1 (IL-1)
    D) Monoclonal immunoglobulin
    E) Vitamin D

    ??
  39. frankyazz

    frankyazz LECOM '14

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    Don't remember the picture exactly, but I think it was osteoporosis, so IL-1 which is a stimulator of osteoclasts. If it was a picture of multiple myeloma, then it would be D.
  40. ruiner

    ruiner

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    is that supposed to look like a dinosaur? cause it does


    couple questions that haven't been asked:

    lle thrombus removed, specimen shows scattered mesenchymal cells in abundant extracellular matrix. - cardiac tumor most likely:

    A)fibroelastoma
    B)fibroma
    C) hamartoma
    d) Hemangioma
    e) Myxoma

    only heart tumors i remember from FA/Uworld are myxoma and rhabodmyomas, didn't think it fit myxoma so guessed fibroma and am thinking it was probably fibroelastoma?

    the one about the guy with paint thinner metabolic acidosis. i guess if i knew what paint thinner was i could probably answer this

    this one is probably pretty dumb but i think i over thought it:
    burning pain with urination, physical exam shows uterine prolapse, mild wbc in urine, bilateral dilation of renal collecting system. greatest risk for:

    cervical carcinoma
    pyelonephritis
    renal cell carcinoma
    ureterolithiasis
    urothelial carcionoma

    i put uretolithiasis because i was thinking well maybe this predisposes her to infection, rather then just putting pyelonephritis which i think is the answer

    23 year old with yellow eyes, low grade fever, nasal congestion, muscle aches, everything else negative, high total, low direct bili, so high indirect bil

    gilbert syndrome
    hepatitis d
    hereditary spheorcytosis
    idiopathic cirrhosis
    steatohepattis

    i put hs but now that i look again i am thinking it was gilbert. obvious its an unconguatedbilirubenima
  41. frankyazz

    frankyazz LECOM '14

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    myxomas are of mesenchymal origin. cervical carcinomas can invade bladder/ureter and cause bilateral dilation of renal collecting system (most common cause of death in cervical caner is post renal azotemia) . And yes probably gilberts. I took this a while ago so I don't exactly remember the questions with the descriptions you gave. Apologies if I am incorrect on anything.
    Last edited: 06.03.12
  42. VisionaryTics

    VisionaryTics Señor Member

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    It was pyelonephritis from urinary stasis. Yes, cervical CA can cause urinary status, but urinary stasis isn't a risk factor for it.
  43. ruiner

    ruiner

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    thanks guys. im pretty much my worst enemy on this thing so far. all 3 i should have had. do now now hopefully not on the test.
  44. takethat12

    takethat12

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    Wait was it osteoporosis or was it too much bone deposition? I couldn't tell. The vertebrae looked osteopenic but then it looked like there was bridging bone around the discs.

    Anyone remember the correct answer to this question?
  45. Zarika

    Zarika

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    This is kind of a dumb one, but I'm not sure on the answer...

    Woman presents to ED with difficulty breathing and severe muscle wekaness for 10 minutes. She has three year history of MG treated with neostigmine. Husband reports se doubled her dosage 2 days ago b/c she was feeling extraordinary weak, but her weakness has increase since then. Which of the following events is the most likely cause of the increased muscle weakness in this patient?
    A) Autoimmune hyperactivation of nicotinic rec
    B) AI inactivation of muscarinic receptors
    C) desensitization of nicotinc receptors
    D) excessive degradation of ACh
    E) hypersensitization of muscarinic receptors
    F) insufficient release of acetylcholine
  46. ipizzy

    ipizzy

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    C - she doubled her neostigmine dose and is now desensitized to acetylcholine
  47. Zarika

    Zarika

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    Thanks, I put E thinking it was some kind of feedback thing
  48. Radonkulous

    Radonkulous

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    I have a few questions that I haven't come across in the thread. Thanks in advance:

    2.8: One regarding woman with enlarged uterus. What is next stop of establishing diagnosis
    measure fsh, tsh, hcg, ultrasound, biopsy. I put ultrasound. Thought it was mole.

    2.18: Man with cirrhosis who has erectile dysfunction. What is decreased?
    estradiol, estrone, fsh, hcg, lh, testosterone. I thought it was lh but my guess it is testosterone.

    2.39: man presents to ed with bruit in lower abdomen. what is going on?
    compression fracture, herniated disc, leaking aortic aneurysm, leaking renal artery aneursym, perforated rectum, perforated sigmoid colon. Thought it was renal artery aneurysm

    3.16: 2 month old dies of meningitis (mycobacterial infection). What is going on?
    Brutons agammaglobulinemia, leukocyte adhesion deficiency, complement deficiency, ifn-gamma receptor problem. I put leukocyte adhesion deficiency.

    3.35: male newborn overreacts to stimuli and has startle response. What was mother using?
    heroin, lsd, marijuana, alcohol, psilocybin. Put marijuana

    4. 19: traveler has watery diarrhea. What do you do to find what he has?
    culture the stool, EM of stool for viruses, microscopic examination of stool for ova and parasites, PCR for shiga toxin, rectal biopsy

    4.21: man doesnt want diabets. what should be his diet?
    low calorie, low carb, low protein, low cholesterol, low protein, low sodium

    4. 29: locate portion of brain which is responsible for decreased touch sensation. not much help without picture

    4.47: mouse has fasting hypoglycemia not corrected with glucagon but with epinephrine. Whats defective?
    adenylyl cyclase, glucagon receptor, glycogen phosphorylase, heterotrimeric G protein, phosphorylase kinase, protein kinase a

    Thanks again in advance!!!!!
  49. Dr McSexy

    Dr McSexy

    Joined:
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    ..
    Those should be it, unless I'm mis-remembering my answers or questions.
  50. Radonkulous

    Radonkulous

    Joined:
    02.27.11
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    Anywhere but here
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    SDN 2+ Year Member
    Thanks a lot for the help. With regards to 2.8, what's wrong with using an ultrasound?
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