NBME 13 discussion

[ijn]

Are we allowed to talk about this topic? There's a NBME 12 discussion that has a lot of full questions posted but there are sticky posts that seem to say don't talk about the NBMEs. Thank you for any clarification!

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[iheartmints]

1. ALS with both LMN (atrophy) and UMN (hyperreflexia) signs --> difficulties swallowing

4. Lithium acts as a ADH antagonist, so think about those effects.

Wow I'm an idiot I thought Li caused SIADH but now I remember it treats it. Thanks!

 

[ijn]

Eek I should have saved this exam until a much later date. Any help is appreciated!!

1) 60 yo carpenter w/ difficulties using tools. Smoked for 45 yrs, drinks lots of alcohol. PE showed no lymphadenopathy. Decr strength in upper and lower extremities (4/5) and atrophy of hand muscles. Has diffuse hyperreflexia. Fasciculations in hands and upper extremity muscles. Sensory exam normal. What do you expect to find in future?
a. Dementia
b. Difficulties swallowing
c. Loss of facial sensation
d. Loss of peripheral vibratory sensation
e. Nystagmus

1) B ; patient has ALS ... they also like to put paralysis of diaphragm as well

2) 55 yo recovers from stroke 2 yrs ago and lives alone. He has incr risk of what?
a) agoraphobia
b) major depressive disorder
c) obsessive compulsive disorder
d) PTSD
e) social phobia

2) B... social isolation, major illness, etc... all risk factors for depression

3) Tracings of skeletal muscle responses to electrical stimulation and asked which one represented the highest amt of calcium sequestered in the SR

The first one is when you have the most calcium in the SR. When you get to the later ones with just a huge continuous contractile spike (tetanus), less calcium is in the SR and more calcium is in the cytosol.

4) Woman on lithium. Tonicity in 3 tubule structures compared to serum (proximal tubule, JGA, medullary collecting duct). I thought it was iso, hypo, hyper but it's not that. Thanks!

She has nephrogenic DI. She can't concentrate her urine via ADH at the medullary collecting ducts so the concentration of urine at the distal tubule will be the same concentration as urine exiting the body. Iso, hypo, hypo.

 

[iheartmints]

Thank you!!!

 

[bacotell]

Does anyone have a better way to explain the studies such as cross sectional, cohort, ect? I get these questions wrong like its my job and Ive never been formally educated on the subject.

Also any one know the answer to man who is sking at high altitude and has orthostatic hypotension? I really think I thought myself out of the right answer on this one becase it was not high altitude sickness as I put. My second was sympathetic disfunction...but I though he would have more symptoms.
Thanks

 

[iheartmints]

Also any one know the answer to man who is sking at high altitude and has orthostatic hypotension? I really think I thought myself out of the right answer on this one becase it was not high altitude sickness as I put. My second was sympathetic disfunction...but I though he would have more symptoms.
Thanks

I'm not sure if I remember it correctly, but wasn't he on acetazolamide? I thought the answer was hypovolemia from use of diuretic. It's not coming up in my missed questions so I assume that actually was it

 

[stardoodler22]

Does anyone have a better way to explain the studies such as cross sectional, cohort, ect? I get these questions wrong like its my job and Ive never been formally educated on the subject.

Thanks

When trying to figure out if it is a cohort vs. case control study, think about the starting point. With case control studies, you start with the outcome (cancer, no cancer, etc) and then look back at exposures (smoking, drug exposure, etc). With cohort studies, you start with exposures and follow them forward looking for outcomes. Remember also that in a case control study, you can only calculate odds ratios, not relative risk. Why? Because relative risk is related to incidence, so if you are predetermining the number of cases and controls, ie. incidence, calculating the relative risk would be pointless (UNLESS, the disease is very rare, and then the odds ratios in this case are a close approximation of the relative risk). In a cohort study, you can assess relative risk, because in this study, the incidence rates should be realistic for the general population (the incident outcomes are naturally occurring, you didn't start by knowing these numbers).

Last, a cross sectional study is just a snapshot in time. For example - taking a random group of people and measuring two (or more) different variables in them, and then making an association. An example would be measuring blood pressure and blood levels of LDL, and then trying to make an association between high and low levels of LDL related to high and low levels of blood pressure. You can never make any sort of causal reasoning in this type of study, because you have no way to make a temporal association (did LDL go up first or did blood pressure go up first?).

I hope that helps. Please let me know if you would like me to clarify anything.

 

[JasonE]

When trying to figure out if it is a cohort vs. case control study, think about the starting point. With case control studies, you start with the outcome (cancer, no cancer, etc) and then look back at exposures (smoking, drug exposure, etc). With cohort studies, you start with exposures and follow them forward looking for outcomes. Remember also that in a case control study, you can only calculate odds ratios, not relative risk. Why? Because relative risk is related to incidence, so if you are predetermining the number of cases and controls, ie. incidence, calculating the relative risk would be pointless (UNLESS, the disease is very rare, and then the odds ratios in this case are a close approximation of the relative risk). In a cohort study, you can assess relative risk, because in this study, the incidence rates should be realistic for the general population (the incident outcomes are naturally occurring, you didn't start by knowing these numbers).

Last, a cross sectional study is just a snapshot in time. For example - taking a random group of people and measuring two (or more) different variables in them, and then making an association. An example would be measuring blood pressure and blood levels of LDL, and then trying to make an association between high and low levels of LDL related to high and low levels of blood pressure. You can never make any sort of causal reasoning in this type of study, because you have no way to make a temporal association (did LDL go up first or did blood pressure go up first?).

I hope that helps. Please let me know if you would like me to clarify anything.

well done. nice 1st post. really bothers me that med schools can't give explanations like this

 

[stardoodler22]

well done. nice 1st post. really bothers me that med schools can't give explanations like this

Thanks! I have a strong stat background; my knowledge of this stuff definitely didn't come from medical school.

I do have another account, but I honestly haven't been been on SDN since MCAT time... I couldn't even remember my previous SN. The stress of these crazy exams brings me back to commiserate with others

 

[bacotell]

Great. Thanks for the studies break down..it my achilles heel going into this exam and I am trying to iron it out before friday. Let you know if I have anymore questions.

Hypovolemia..doh. I reallllly out foxed myself on that one. I ruled it out becuase I thought his sympathetics would be able to compensate and prevent orthostatic hypotension..but I guess they cannot compensate enough. Thanks amigo.

Best of luck to you all.

 

[kalyanmedico]

guys exam in 4 days .....few questions in NBME 13 that i couldnt get answers to ....please help me out on this

1)the question where there was a non displaced frac of clavicle ....cells helping in forming new bone?....is the answer lamella ?..i picked haversian canals ...and it was wrong

2)elderly woman with pleural effusion dullness at 7 th rib and below ...thoracentesis to be done ...best site for insertion of the catheter...

3)52 yr old family h/o renal failure ...prev treated for HTN and renal calculi urine analysis showing crenated RBC what ever that means ....asking for CT diagnosis ..... options glomerulonephritis ....adrenal adenoma ...renal cell adenoma ...PKD ....HSP?

4)raised red cystic lesion from ant neck .....hemangioma derived from ..?endothelium...NC ...notochord ...yolksac?...ectoderm?

5)22 yr old bloke with cystic lesion at side of neck....due to incomplete fusion due to embryogenesis ....asking for site where the duct leading to the mass opens?...what is the diagnosis on that one ...i picked duct opening behind the parotid and was wrong....it was a fluke ....

6)missense mutation of tyrosine kinase domian ....which of the following is disrupted....is the answer phosphorylation of downstream molecules in response to Nerve growth factor?

7)...pseudo monas auerguinosa infection .....not controlled with antibiotics ...reason for persistant colonisation ...i picked growth of acapsular strains and it wrong


8)method of preventing spread of kleb infec to other patients around......i picked wearing of face masks by the phycisians ....that was wrong....is it air exchanges every hour or hand cleansning?

9) docs dad dies of alcoholism ....doc getting frustrated and angry with any patient who is a alcoholic ....the defence mechanism he adapts to control this ....reppression ...suppression ...reaction formation(wrong)...projection ...denial

10)15 yr old lad with unilateral breat swelling ....best initial statement by physician ?
have u tried smokin marjuana recently?....or this is a common condition of your age and it will reslove ...?this a a serious condition and more tests are to be done ...sus pecting a chromosomal anomaly ..?i picked some teenagers experiment with their parents prescrip drugs (wrong)



Thanks for the answers!!

 

[JasonE]

guys exam in 4 days .....few questions in NBME 13 that i couldnt get answers to ....please help me out on this

1)the question where there was a non displaced frac of clavicle ....cells helping in forming new bone?....is the answer lamella ?..i picked haversian canals ...and it was wrong

2)elderly woman with pleural effusion dullness at 7 th rib and below ...thoracentesis to be done ...best site for insertion of the catheter...

3)52 yr old family h/o renal failure ...prev treated for HTN and renal calculi urine analysis showing crenated RBC what ever that means ....asking for CT diagnosis ..... options glomerulonephritis ....adrenal adenoma ...renal cell adenoma ...PKD ....HSP?

4)raised red cystic lesion from ant neck .....hemangioma derived from ..?endothelium...NC ...notochord ...yolksac?...ectoderm?

5)22 yr old bloke with cystic lesion at side of neck....due to incomplete fusion due to embryogenesis ....asking for site where the duct leading to the mass opens?...what is the diagnosis on that one ...i picked duct opening behind the parotid and was wrong....it was a fluke ....

6)missense mutation of tyrosine kinase domian ....which of the following is disrupted....is the answer phosphorylation of downstream molecules in response to Nerve growth factor?

7)...pseudo monas auerguinosa infection .....not controlled with antibiotics ...reason for persistant colonisation ...i picked growth of acapsular strains and it wrong


8)method of preventing spread of kleb infec to other patients around......i picked wearing of face masks by the phycisians ....that was wrong....is it air exchanges every hour or hand cleansning?

9) docs dad dies of alcoholism ....doc getting frustrated and angry with any patient who is a alcoholic ....the defence mechanism he adapts to control this ....reppression ...suppression ...reaction formation(wrong)...projection ...denial

10)15 yr old lad with unilateral breat swelling ....best initial statement by physician ?
have u tried smokin marjuana recently?....or this is a common condition of your age and it will reslove ...?this a a serious condition and more tests are to be done ...sus pecting a chromosomal anomaly ..?i picked some teenagers experiment with their parents prescrip drugs (wrong)



Thanks for the answers!!

1. periosteum. anytime they ask about bone pain/regeneration, answer ir periosteum.

2. above 9th rib midscapular line not sure why this was right though becuase i thought you would hit the lung at that point.

3. PKD. they were a little vague, but a key was that they used CT to diagnose.

4. endothelium

5. anterior to sternocleidomastoid. weird way of asking it i thought, but its a branchial cleft cyst i believe.

6. phosphorylation

7. biofilm. they said antibiotics werent working. good sign it was bioflim, which is like a bunker for the bugs to hide in

8. uggg annoying one, but it was handwashing. my hint is if they ever ask how to prevent something and you dont know, put handwashing.

9. suppression. hes chosing to forget about it.

10. totally normal. for these questions, if you dont know the answer, i would always put its normal or dont treat. they're probably trying to see if you know the condition they are talking about will self resolve.

 

[kalyanmedico]

1. periosteum. anytime they ask about bone pain/regeneration, answer ir periosteum.

2. above 9th rib midscapular line not sure why this was right though becuase i thought you would hit the lung at that point.

3. PKD. they were a little vague, but a key was that they used CT to diagnose.

i thought HTN was more common with medullary sponge kidney ...does PKD also result in HTN ?


4. endothelium

5. anterior to sternocleidomastoid. weird way of asking it i thought, but its a branchial cleft cyst i believe.

6. phosphorylation

7. biofilm. they said antibiotics werent working. good sign it was bioflim, which is like a bunker for the bugs to hide in
I thought biofilm was only produced by strep .viridans ....ill remember that

8. uggg annoying one, but it was handwashing. my hint is if they ever ask how to prevent something and you dont know, put handwashing.
that was a really tricky one !!.....

9. suppression. hes chosing to forget about it.

10. totally normal. for these questions, if you dont know the answer, i would always put its normal or dont treat. they're probably trying to see if you know the condition they are talking about will self resolve.

Thanks a lot mate ...thats was a huge relief .....really needed those answers....

 

[kaleerkalut]

Some help with the following would be really appreciated as I'm 4 days out from test day:

1. 20 subjects participate in a study of ardiopulmonary physiology. The pulmonary circulation of these subjects most likely has which fof the following characeteristscs compared w/ their bronchial circulation?
a) greater number of branches supplying the visceral pleura
b) larger number of asntomoses w/ interecostal arteries
c) larger percentrage of cardiac output
d) larger volume of nutrient blood to the conducting airways (WRONG )
e) lower volume, higher pressure system

2. 10 yr old boy who has had T1DM for 1 year is receiving insulin. One hour after his morning dose of insulin he becomes tremulous and diaphroetic and has tachycardia. Several hours later his symptoms resolve. His blood glucose concentration is now increased. Which of the following is the most likely cause of this patient's hyperglycemia?

a) activation of hepatic adenylyl cyclase
b) activation of muscle glycogen synthase
c) activation of muscle phosphorylase (WRONG )
d) activation of muscle protein phosphatase
e) inhibition of hepatic protein kinase A

3. A study is conducted to evaluate the onset and course of cardiovascular disease in African American men and women in the USA. Census data from the year 2000 are used to select the study sample. A series of factors including family income and years of education is defined. Census tracts most representative of the national census data for the factors selected are used for sampling. Which of the following best describes this sampling technique?

a) blocked randomization
b) population-based
c) sample of convenience (WRONG )
d) self-selection
e) sequential

4. 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

5. Too long to write out but it was a question w/ kid w/ Duchenne's and asked which insertion point for adduction?

a) anterior sacrum
b) iliac crest (WRONG )
c) iliac spine
d) ischium
e) lateral ilium

6. The calculation question for Loading Dose: I just did Vd x Cp x 33 kg (55kg x .6 for TBW)
---I picked 100 but it was wrong

7. The question about the 2 hour 75 g of oral glucose and the up and down arrows for triglycerides, HDL-cholesterol, free fatty acids. What was the answer?

THANK YOU ALL VERY MUCH

 

[kalyanmedico]

Some help with the following would be really appreciated as I'm 4 days out from test day:

1. 20 subjects participate in a study of ardiopulmonary physiology. The pulmonary circulation of these subjects most likely has which fof the following characeteristscs compared w/ their bronchial circulation?
a) greater number of branches supplying the visceral pleura
b) larger number of asntomoses w/ interecostal arteries
c) larger percentrage of cardiac output
d) larger volume of nutrient blood to the conducting airways (WRONG )
e) lower volume, higher pressure system

2. 10 yr old boy who has had T1DM for 1 year is receiving insulin. One hour after his morning dose of insulin he becomes tremulous and diaphroetic and has tachycardia. Several hours later his symptoms resolve. His blood glucose concentration is now increased. Which of the following is the most likely cause of this patient's hyperglycemia?

a) activation of hepatic adenylyl cyclase
b) activation of muscle glycogen synthase
c) activation of muscle phosphorylase (WRONG )
d) activation of muscle protein phosphatase
e) inhibition of hepatic protein kinase A

3. A study is conducted to evaluate the onset and course of cardiovascular disease in African American men and women in the USA. Census data from the year 2000 are used to select the study sample. A series of factors including family income and years of education is defined. Census tracts most representative of the national census data for the factors selected are used for sampling. Which of the following best describes this sampling technique?

a) blocked randomization
b) population-based
c) sample of convenience (WRONG )
d) self-selection
e) sequential

4. 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

5. Too long to write out but it was a question w/ kid w/ Duchenne's and asked which insertion point for adduction?

a) anterior sacrum
b) iliac crest (WRONG )
c) iliac spine
d) ischium
e) lateral ilium

6. The calculation question for Loading Dose: I just did Vd x Cp x 33 kg (55kg x .6 for TBW)
---I picked 100 but it was wrong

7. The question about the 2 hour 75 g of oral glucose and the up and down arrows for triglycerides, HDL-cholesterol, free fatty acids. What was the answer?

THANK YOU ALL VERY MUCH

1) the pulm circulation has a larger percentage of CO compared to bronchail

2)activation of hep adenylyl cyclase

3)popu based

4)volt gated Na

5)ischium

6)you have to multiply the Vd with body wt before calulating the LD

 

[kaleerkalut]

1) the pulm circulation has a larger percentage of CO compared to bronchail

2)activation of hep adenylyl cyclase

3)popu based

4)volt gated Na

5)ischium

6)you have to multiply the Vd with body wt before calulating the LD

Thank you! By the way, have you taken Step 1 or just NBME 13? I feel like I missed some easy ones just because I was tired and haven't been sleeping well. Sigh...

If anybody can help out w/ #7 I'd really appreciate it.

 

[ijn]

The answer to #7 is increased triglycerides, decreased HDL, and increased free fatty acids. Remember insulin is important to activating lipoprotein lipase and the uptake of fat into the peripheral adipose tissues. If you're resistant to insulin then your triglyceride levels are high. I forgot why HDL goes down. I just have it burned in my head that you lose "good" cholesterol in unhealthy metabolic states and you become predisposed to large vessel atherosclerosis, which is what ultimately kills most diabetics.

You didn't really have to know about the FFA though, since there was only one answer choice with a down arrow on HDL and up arrow on TGs.

 

[kalyanmedico]

my step 1 is in a couple of days .....dont stress yourself out too much .....youl do well if you stay cool ..... : )

 

[drmsms]

A 22yr nulligravid woman comes to the physician bcz she is uable to conceive since 18months.she has had irregular menses since her menarche at the age of 13.she is 165cm tall n wt 88kg.BMI 32.pulse 88/min RR14/min BP 140/90mmhg.physical examination shows moderate hirsutism and mild acne on face and back.pelvic exam shows normal ext,genitalia.Bimanual examination is limited due to pt's obesity.which is the most likely cause of her infertility?

A. Hypothyroidism
B. Klinifelter synd
C. Pitutary adenoma
D. Polycystic ovarian dz.
E. Primary ovarian failure.

 

[iheartmints]

A 22yr nulligravid woman comes to the physician bcz she is uable to conceive since 18months.she has had irregular menses since her menarche at the age of 13.she is 165cm tall n wt 88kg.BMI 32.pulse 88/min RR14/min BP 140/90mmhg.physical examination shows moderate hirsutism and mild acne on face and back.pelvic exam shows normal ext,genitalia.Bimanual examination is limited due to pt's obesity.which is the most likely cause of her infertility?

A. Hypothyroidism
B. Klinifelter synd
C. Pitutary adenoma
D. Polycystic ovarian dz.
E. Primary ovarian failure.

I think it's D

wiki:
Common symptoms of PCOS include:
menstrual disorders, infertility, high levels of masculizing hormones, metabolic syndrome

I don't see it in my list of questions and I think that's what I picked

 

[mdeast]

I think it's D

wiki:
Common symptoms of PCOS include:
menstrual disorders, infertility, high levels of masculizing hormones, metabolic syndrome

I don't see it in my list of questions and I think that's what I picked

Yeah this is classic PCOS. This may sound inappropriate, but be "racist" on Step 1. They try and usually present you with the prototypical presentation of a disease. Also, ask yourself....why did they tell my the patient's BMI? Why did they add a section about "Bimanual exam is limited by obesity". If you see they are pointing out something oddly specific (i.e. this patient works at a shipyard, this patient works for NASA, this patient makes clothing at wool factory, etc.) it usually relates specifically as the big clue to the diagnosis.

"An overweight woman with fertility problems" is almost always going to have PCOS.

 

[drmsms]

thank you for the ans.Here comes one more Q...
A study conducted to assess the effectiveness of vit,C in preventing common cold in children.Pts are randomly signed to either receive vit.C or no intervention. Outcome events(common cold)are reported by the pts on monthly basis for 1year.Results show that pts taking vit.C have fewer colds compared with those who received no intervention(p<0.05).which of the following raises the most concern about the validity of conclusion that vit.C prevents cold?
A. Inadequate statistical power
B. Nonrandomisation
C. Selection bias
D. Variability in outcome assessment

 

[ijn]

The answer is "variability in outcome assessment." You're not measuring lab values or some other objective form of evaluation. You're measuring a subjective "do you feel better" after giving an intervention. People will think they get less colds because that's what they've been told by the supplement industry and the media.

 

[drmsms]

that was a nice explaination...thank you

 

[jgold16]

An epidemiologist is investigating an outbreak of diarrhea among a total of 1000 consumers of vegetables. Of those consumers, 800 people at tomatoes and 200 people ate lettuce. A total of 400 people became ill; 80 of these people ate tomatoes, and 40 people ate lettuce. Which of the following indicates the probability of diarrhea having developed in people who consumed lettuce?
A. 0.08
B. 0.1 wrong
C. 0.2
D. 0.4
E. 0.5

I think I misinterpreted the question to be: out of the people with diarrhea was was the probability they were a lettuce eater.

Any help? I suck terribly at these math problems.

 

[ijn]

40/200 = 0.2

# of people who have diarrhea from lettuce / # of people who ate lettuce

 

[PlaceboEffect]

An epidemiologist is investigating an outbreak of diarrhea among a total of 1000 consumers of vegetables. Of those consumers, 800 people at tomatoes and 200 people ate lettuce. A total of 400 people became ill; 80 of these people ate tomatoes, and 40 people ate lettuce. Which of the following indicates the probability of diarrhea having developed in people who consumed lettuce?
A. 0.08
B. 0.1 wrong
C. 0.2
D. 0.4
E. 0.5

I think I misinterpreted the question to be: out of the people with diarrhea was was the probability they were a lettuce eater.

Any help? I suck terribly at these math problems.

Something that bothered me about this question: if 400 people got sick and 80 ate tomatoes and 40 ate lettuce, what did the other 280 people eat? Both? Neither?

 

[kaleerkalut]

Does anybody remember the question about the toxic product of acetominophen and alcohol? I think I picked hepatic sulfation but I had no idea why and its nowhere in FA or in Kaplan Pharm. Can anybody help out on this one?

 

[Morsetlis]

Does anybody remember the question about the toxic product of acetominophen and alcohol? I think I picked hepatic sulfation but I had no idea why and its nowhere in FA or in Kaplan Pharm. Can anybody help out on this one?

42 year old man presents with 4 week history of muscle pain. Patient started simvastatin 2 months ago and gemfibrozil 4 weeks ago. The patient's myalgia is due to which of the following effects gemfibrozil has on simvastatin?

A- Decreased bioavailability
B- Increased absorption
C- Inhibition of cytochrome p450
D- Inhibition of hepatic glycosylation
E- Inhibiton of hepatic sulfation

"There are several theories explaining the increased risk of muscle toxicity
when statins and fibrates are combined. These include additive effects of statins and
fibrates on skeletal muscle resulting in the increased risk, displaced protein binding (all
statins are highly protein bound), and finally, inhibition of a recently recognized mode of
statin metabolism via glucuronidation. Gemfibrozil and fenofibrate both undergo
glucuronide-mediated metabolism. In two in-vitro studies using human and dog
hepatocytes, the glucuronide mediated-metabolism of atorvastatin acid, simvastatin acid,
cerivastatin acid and rosuvastatin acid were all inhibited by gemfibrozil."

http://www.pbm.va.gov/Safety Reports/87ry38statin-fibrate-Final.pdf

It's competitive inhibition of phase II conjugation, of which you should pick from sulfation or glucuronidation (not glycosylation).

Acetaminophen also undergoes sulfation and glucuronidation. CYP450 2E1 will conjugate it into toxic NAPQI too at high concentration (treat with glutathion / NACysteine)

 

[bmr6819]

.

 

[ijn]

Here are a few of my questions. If possible, can someone explain the answers to the last 2 questions. I get my glucagon/epi stuff mixed up...and the last question is just plain confusing (for me). Thanks!


Autopsy on a 46 yo woman who died of adenocarcinoma of the colon. Exam of neck shows 5 cm roundd mass next to bifurcation of carotid artery. Immunohistochemistry is positive for synaptophysin, chromogranin and neuron-specific enolase. EM show numerous electron dense, membrane bound neurosecretory granules. Exam of adrenal glands shows no masses. Most likely diagnosis?
A. metastatic colon CA
B. metastatic Squamous cell carcinoma of larynx
C. papillary carcinoma of the thyroid gland
D. paraganglioma
E. parathyroid adenoma (wrong)

Paragangliomas are found near the carotid body. That was a really nit picky question. I only knew what a paraganglionoma because my school's lecture talked about it for all of 2 minutes. I haven't seen it in any other STEP 1 review source. Although based on the description of the cancer as neural or neuroendocrine, you should be able to eliminate any tumor that's related to endodermal or epidermal tissues without really knowing what a paraganglionoma is. Now if they made you pick between paraganglionoma and a metastatic carcinoid tumor, then it might be a little harder and you'd actually have to know the most likely location you'd find each of those tumors.

32 yo woman with 1 mo hx of progressive SOB and anxiety. Her symptoms become much more pronounced as the day progresses. BMI 24. Breath sounds are normal on auscultation of chest, but the pt has difficulty taking a long, deep breath. Arterial blood gas analysis on room air shows pH 7.33; pCO2 70; pO2 65. Pulmonary function testing shows decreased vital capacity, tidal volume and expiratory reserve volume. Her residual volume is within reference range. Which is the most likely underlying cause of this patient's condition?
A. alpha antitrypsin deficiency (no)
B. CNS neoplasm
C. Chronic bronchitis (no)
D. Chronic opiate use (wrong)
E. Myasthenia gravis (yes???)
F. Obesity

Myasthenia gravis is correct.

an investigator breeds a transgenic strain of mice that develops severe fasting hypoglycemia. Admin of glucagon does not correct the hypoglycemia, but admin of epinephrine results in an increase in serum glucose concentration. Which is most likely defective in this mouse strain?
A. adenylyl cyclase (wrong)
B. glucagon Receptor
C. glycogen phosphorylase
D. heterotrimeric G protein
E. phosphorylase kinase
F. protein kinase A

If PKA, adenylate cyclase or the heterotrimeric G protein were defective, both stimulation by glucagon and epinephrine would be ineffective since those components are part of a shared pathway. Therefore it's the glucagon receptor associated with the G(s) protein. The epinephrine receptor is still funtioning, so it can activate G(s) and promote gluconeogenesis.

A researcher in a pharm company designs a new protease inhibitor that inhibits replication of HIV in T lymphocytes in culture. In subsequent assays, which of the following findings is most likely to indicate that the compound is working specifically as a protease inhibitor?
A. the drug prevents integration of proviral DNA into host genome
B. the RNA is partially reverse transcribned into proviral DNA
C. there is lack of mature core
D. transcription from the HIV promoter is blocked
E. the virus does not bind to CD4 in the presence of the drug (wrong)

There is a lack of a mature core which requires protease to be formed.

A is referring to integrase inhibitors (raltegravir), B is referring to NRTI/NNRTIs, I don't think there is a drug on the market for D, and I think E is either referring to a soluble CCR5 receptor (maraviroc) or a fusion inhibitor (enfuvurtide).

 

[JasonE]

for the paraganglionoma one, you dont really need to know the answer to get the question right. just know chromogramin --> small cell cancer of the lung and carninoid (neurosecretory tumors, which they even tell you). from that, you can eliminate all the other ones and clearly paraganglionoma has something to do with neurons so it fits

 

[Morsetlis]

an investigator breeds a transgenic strain of mice that develops severe fasting hypoglycemia. Admin of glucagon does not correct the hypoglycemia, but admin of epinephrine results in an increase in serum glucose concentration. Which is most likely defective in this mouse strain?
A. adenylyl cyclase (wrong)
B. glucagon Receptor
C. glycogen phosphorylase
D. heterotrimeric G protein
E. phosphorylase kinase
F. protein kinase A

A researcher in a pharm company designs a new protease inhibitor that inhibits replication of HIV in T lymphocytes in culture. In subsequent assays, which of the following findings is most likely to indicate that the compound is working specifically as a protease inhibitor?
A. the drug prevents integration of proviral DNA into host genome
B. the RNA is partially reverse transcribned into proviral DNA
C. there is lack of mature core
D. transcription from the HIV promoter is blocked
E. the virus does not bind to CD4 in the presence of the drug (wrong)

Please include block/q number in the future so I can double check my answer, lol.

2: Gluc and Epi are both activating AC (and the rest of the choices are part of their common pathway). Thus, the Gluc receptor sucks, the Epi receptor is fine.

3: When viral RNA is translated into a polypeptide sequence, that sequence is assembled in a long chain that includes several individual proteins (reverse transcriptase, protease, integrase). Before these enzymes become functional, they must be cut from the longer polypeptide chain. Viral protease cuts the long chain into its individual enzyme components which then facilitate the production of new viruses. Inhibition leads to a lack of a mature core.

 

[bmr6819]

.

 

[kaleerkalut]

42 year old man presents with 4 week history of muscle pain. Patient started simvastatin 2 months ago and gemfibrozil 4 weeks ago. The patient's myalgia is due to which of the following effects gemfibrozil has on simvastatin?

A- Decreased bioavailability
B- Increased absorption
C- Inhibition of cytochrome p450
D- Inhibition of hepatic glycosylation
E- Inhibiton of hepatic sulfation

"There are several theories explaining the increased risk of muscle toxicity
when statins and fibrates are combined. These include additive effects of statins and
fibrates on skeletal muscle resulting in the increased risk, displaced protein binding (all
statins are highly protein bound), and finally, inhibition of a recently recognized mode of
statin metabolism via glucuronidation. Gemfibrozil and fenofibrate both undergo
glucuronide-mediated metabolism. In two in-vitro studies using human and dog
hepatocytes, the glucuronide mediated-metabolism of atorvastatin acid, simvastatin acid,
cerivastatin acid and rosuvastatin acid were all inhibited by gemfibrozil."

http://www.pbm.va.gov/Safety Reports/87ry38statin-fibrate-Final.pdf

It's competitive inhibition of phase II conjugation, of which you should pick from sulfation or glucuronidation (not glycosylation).

Acetaminophen also undergoes sulfation and glucuronidation. CYP450 2E1 will conjugate it into toxic NAPQI too at high concentration (treat with glutathion / NACysteine)

Thanks for your response. That last line refers to my question but the stuff above is a different question. Really appreciate the efforts!

Quick question since I didn't get a solid answer in the other thread:

Is this the link for doing the tutorial (i.e. do you have to do the 22 MB download)?

http://usmle.org/practice-materials/index.html

I'm taking step 1 in ~24 hours so I'd really appreciate anybody's response. Thanks again to everyone

 

[drmsms]

Thanks for your response. That last line refers to my question but the stuff above is a different question. Really appreciate the efforts!

Quick question since I didn't get a solid answer in the other thread:

Is this the link for doing the tutorial (i.e. do you have to do the 22 MB download)?

http://usmle.org/practice-materials/index.html

I'm taking step 1 in ~24 hours so I'd really appreciate anybody's response. Thanks again to everyone

go to www.usmle.org and download the fredx software for the practice test.Gudluck for your exam

 

[drmsms]

Q.A prospective study examined the relationship between the development of gastric cancer and exposure to a diet rich in selenium. The investigators estimated the relative risk of gastic cnacer to be 0.3 in individuals with a high-selenium diet (95% confidence interval 0.1-0.8). Which of the following is the most appropriate interpretation of this finding?
A) Selenium causes gastric cancer
B) Selenium exposure is unrelated to gastric cancer
C) Selenium is associated with a higher risk of gastric cancer (wrong)
D) Selenium is associated with a lower risk of gastric cancer
E) Selenium is positively correlated with gastric cancer

 

[Morsetlis]

Q.A prospective study examined the relationship between the development of gastric cancer and exposure to a diet rich in selenium. The investigators estimated the relative risk of gastic cnacer to be 0.3 in individuals with a high-selenium diet (95% confidence interval 0.1-0.8). Which of the following is the most appropriate interpretation of this finding?
A) Selenium causes gastric cancer
B) Selenium exposure is unrelated to gastric cancer
C) Selenium is associated with a higher risk of gastric cancer (wrong)
D) Selenium is associated with a lower risk of gastric cancer
E) Selenium is positively correlated with gastric cancer

A neutral risk is 1.
A is an absolute, so it's pretty silly and is wrong. B is also another absolute.
RR <1 means exposure reduces relative risk of getting the disease.
RR >1 means exposure increases relative risk of getting the disease.

Selenium correlates with lower risk of gastric cancer.

Glutathione peroxidase uses Glutathione, and Selenium as a cofactor to convert peroxides into water, thus reducing oxidative damage to the colon. Incidentally, the GI cancer rate in Grenada is huge due to all the BBQ food.

 

[drmsms]

very well explained....thankyou
a 55yr old woman is scheduled to undergo transvaginal hysterectomy and oopherectomy for DUB. During the procedure the uterus must be separated from all the pelvic organs.Identification and inscission of which of the following structures that attaches to cervical region and extends posteriorly is most appropriate in this pt?
A. Mesometrium
B. Mesosalpinx
C. Mesovarium
D. Ovarian lig
E. Round lig of uterus
F. Uterosacral lig

 

[krisrad]

very well explained....thankyou
a 55yr old woman is scheduled to undergo transvaginal hysterectomy and oopherectomy for DUB. During the procedure the uterus must be separated from all the pelvic organs.Identification and inscission of which of the following structures that attaches to cervical region and extends posteriorly is most appropriate in this pt?
A. Mesometrium
B. Mesosalpinx
C. Mesovarium
D. Ovarian lig
E. Round lig of uterus
F. Uterosacral lig

I think I put "uterosacral ligament" as that was the only one that extends posteriorly from the uterus.

I have a few questions of my own:

1. An investigator is studying beta2-receptors in female experimental animals. Epinephrine is injected intramuscularly into the animals, and the effects on beta2-adrenoreceptors are then observed. Which of the following physiologic effects is most likely to be observed in these animals?
A) Increased myocardial contractility
B) Internal urethral sphincter contraction
C) Lipolysis (WRONG)
D) Pilomotor contraction
E) Pupillary dilation
F) Uterine relaxation (RIGHT?)

So, I put lipolysis, which was wrong. I bet the answer is uterine relaxation, but I thought both uterine relaxation and lipolysis were possible. I don’t understand why lipolysis is wrong. Is it just because you would observe uterine relaxation QUICKER than you would “observe” lipolysis? Or, have I finally lost it and am failing to see something obvious?

2. A 33yo woman presents with a mass in her upper outer quadrant. Examination shows 2.5 cm, hard mass. Photograph of the resected mass is shown. Which of the following characteristics best predicts this patient’s prognosis?
A) Degree of differentiation of the cells comprising the lesion
B) DNA content of the cells comprising the lesion
C) Lymph node involvement (RIGHT?)
D) Presence or absence of hormone receptors within the lesion (WRONG)
E) Size of the lesion

3. A 22 y/o woman comes to the physician for a follow-up examination. One year ago, she was diagnosed with a pulmonary embolism. Two years ago, she delivered a female stillborn at 23 weeks’ gestation. Physical examination today shows no abnormalities. Lab studies show a normal platelet count, normal prothrombin time, and increased partial thromboplastin time. The findings in this patient are most consistent with which of the following conditions?
A) Antiphospholipid antibody syndrome (RIGHT?)
B) Factor V Leiden mutation
C) Increased factor VIII (antihemophilic factor) concentration
D) Protein C deficiency (WRONG)
E) Prothrombin G20210A mutation

So, the patient has a clotting problem (DVT + miscarriage), but an increased PTT (bleeding problem) as well. I had no idea which disorder could account for both (the closest I can get is something like DIC, but that wasn’t on the list). After some Google-ing, I guess it’s probably antiphospholipid antibody syndrome. I just want someone to confirm with an explanation, if possible. I don’t think this disease is even in FA (unless I’m mistaken). My Robbins’ pathology had only one sentence on it.

Stupid NBME 13. Did so badly.

 

[ijn]

very well explained....thankyou
a 55yr old woman is scheduled to undergo transvaginal hysterectomy and oopherectomy for DUB. During the procedure the uterus must be separated from all the pelvic organs.Identification and inscission of which of the following structures that attaches to cervical region and extends posteriorly is most appropriate in this pt?
A. Mesometrium
B. Mesosalpinx
C. Mesovarium
D. Ovarian lig
E. Round lig of uterus
F. Uterosacral lig

Yeah, it's urterosacral.

 

[PeterParker7]

very well explained....thankyou
a 55yr old woman is scheduled to undergo transvaginal hysterectomy and oopherectomy for DUB. During the procedure the uterus must be separated from all the pelvic organs.Identification and inscission of which of the following structures that attaches to cervical region and extends posteriorly is most appropriate in this pt?
A. Mesometrium
B. Mesosalpinx
C. Mesovarium
D. Ovarian lig
E. Round lig of uterus
F. Uterosacral lig

I think I ended up guessing Uterosacral. It didn't come up on my incorrects.

 

[PeterParker7]

I think I put "uterosacral ligament" as that was the only one that extends posteriorly from the uterus.

I have a few questions of my own:

1. An investigator is studying beta2-receptors in female experimental animals. Epinephrine is injected intramuscularly into the animals, and the effects on beta2-adrenoreceptors are then observed. Which of the following physiologic effects is most likely to be observed in these animals?
A) Increased myocardial contractility
B) Internal urethral sphincter contraction
C) Lipolysis (WRONG)
D) Pilomotor contraction
E) Pupillary dilation
F) Uterine relaxation (RIGHT?)

It was uterine relaxation. B2 agonists like tertbutaline are used for this. As for lipolysis, I think that involves alpha 2, not beta 2. i think its in FA Pharm

2. A 33yo woman presents with a mass in her upper outer quadrant. Examination shows 2.5 cm, hard mass. Photograph of the resected mass is shown. Which of the following characteristics best predicts this patient’s prognosis?
A) Degree of differentiation of the cells comprising the lesion
B) DNA content of the cells comprising the lesion
C) Lymph node involvement (RIGHT?)
D) Presence or absence of hormone receptors within the lesion (WRONG)
E) Size of the lesion

Lymph node is right. TMN staging is best for prognosis determination. Mets pretty much always indicate worse prognosis.

3. A 22 y/o woman comes to the physician for a follow-up examination. One year ago, she was diagnosed with a pulmonary embolism. Two years ago, she delivered a female stillborn at 23 weeks’ gestation. Physical examination today shows no abnormalities. Lab studies show a normal platelet count, normal prothrombin time, and increased partial thromboplastin time. The findings in this patient are most consistent with which of the following conditions?
A) Antiphospholipid antibody syndrome (RIGHT?)
B) Factor V Leiden mutation
C) Increased factor VIII (antihemophilic factor) concentration
D) Protein C deficiency (WRONG)
E) Prothrombin G20210A mutation

Yeah, sounds like she has antiphospholipids Ab syndrome. Not sure how to explain the PTT, but that was the right answer. I think I must have glazed over the PTT part and went for answer A after seeing PE/abortion.

Stupid NBME 13. Did so badly.

It was a tough test. Probably harder than others because review material isn't as up to date for this as compared to the others. Just keep at it though!

 

[ijn]

I think I put "uterosacral ligament" as that was the only one that extends posteriorly from the uterus.

I have a few questions of my own:

1. An investigator is studying beta2-receptors in female experimental animals. Epinephrine is injected intramuscularly into the animals, and the effects on beta2-adrenoreceptors are then observed. Which of the following physiologic effects is most likely to be observed in these animals?
A) Increased myocardial contractility
B) Internal urethral sphincter contraction
C) Lipolysis (WRONG)
D) Pilomotor contraction
E) Pupillary dilation
F) Uterine relaxation (RIGHT?)

Beta 2 adrenergic receptors stimulate G(s) which relaxes smooth muscle in the uterus. I'm not sure why lipolysis is a wrong answer honestly. Perhaps because epinephrine would stimulate alpha 2 and beta 2 simultaneously, then you would get a net zero effect on lipolysis.

2. A 33yo woman presents with a mass in her upper outer quadrant. Examination shows 2.5 cm, hard mass. Photograph of the resected mass is shown. Which of the following characteristics best predicts this patient's prognosis?
A) Degree of differentiation of the cells comprising the lesion
B) DNA content of the cells comprising the lesion
C) Lymph node involvement (RIGHT?)
D) Presence or absence of hormone receptors within the lesion (WRONG)
E) Size of the lesion

Stage is always the most important characteristic for breast cancer.

3. A 22 y/o woman comes to the physician for a follow-up examination. One year ago, she was diagnosed with a pulmonary embolism. Two years ago, she delivered a female stillborn at 23 weeks' gestation. Physical examination today shows no abnormalities. Lab studies show a normal platelet count, normal prothrombin time, and increased partial thromboplastin time. The findings in this patient are most consistent with which of the following conditions?
A) Antiphospholipid antibody syndrome (RIGHT?)
B) Factor V Leiden mutation
C) Increased factor VIII (antihemophilic factor) concentration
D) Protein C deficiency (WRONG)
E) Prothrombin G20210A mutation

Spontaneous abortions are a huge buzz word for lupus anticoagulant. I think the best way to remember is that those antibodies are IgG, so they will cross into the placenta and wreck havoc. Also, Factor V Leiden and protein C deficiency would not have an elevated PTT since they're hypercoagluable states without any antibodies to screw up the PTT test. An elevated PTT should mean you are NOT clotting, but in lupus the antibodies are causing false elevations in the PTT. A high PTT and hypercoagluablility should at first appear to be contradictory if you understand the clotting cascade.

The only things that cause elevated PTT that we're responsible for:
Lupus anticoagulant antibodies: hypercoagluable, false positive VLDR, spontaneous abortions, and the PTT will stay elevated despite addition of clotting factors
Anti factor VIII antibodies: hypocoagluable and PTT will stay elevated despite addition of clotting factors
Hemophilia A/B: hypocoagluable and elevated PTT will be corrected with clotting factors, problems with secondary hemostasis (hemoarthrosis, etc)
Liver failure: hypocoagluable and PT should also be elevated, hyperammonemia, signs hyperestrogenism, etc.
vWF deficiency: hypocoagluable state, problems in primary hemostasis (epistaxis, bleeding w/ dental procedures), negative ristocetan test, etc.
Exogenous heparin: hypocoagluable state

 

[JasonE]

I think I put "uterosacral ligament" as that was the only one that extends posteriorly from the uterus.

I have a few questions of my own:

1. An investigator is studying beta2-receptors in female experimental animals. Epinephrine is injected intramuscularly into the animals, and the effects on beta2-adrenoreceptors are then observed. Which of the following physiologic effects is most likely to be observed in these animals?
A) Increased myocardial contractility
B) Internal urethral sphincter contraction
C) Lipolysis (WRONG)
D) Pilomotor contraction
E) Pupillary dilation
F) Uterine relaxation (RIGHT?)

So, I put lipolysis, which was wrong. I bet the answer is uterine relaxation, but I thought both uterine relaxation and lipolysis were possible. I don’t understand why lipolysis is wrong. Is it just because you would observe uterine relaxation QUICKER than you would “observe” lipolysis? Or, have I finally lost it and am failing to see something obvious?

2. A 33yo woman presents with a mass in her upper outer quadrant. Examination shows 2.5 cm, hard mass. Photograph of the resected mass is shown. Which of the following characteristics best predicts this patient’s prognosis?
A) Degree of differentiation of the cells comprising the lesion
B) DNA content of the cells comprising the lesion
C) Lymph node involvement (RIGHT?)
D) Presence or absence of hormone receptors within the lesion (WRONG)
E) Size of the lesion

3. A 22 y/o woman comes to the physician for a follow-up examination. One year ago, she was diagnosed with a pulmonary embolism. Two years ago, she delivered a female stillborn at 23 weeks’ gestation. Physical examination today shows no abnormalities. Lab studies show a normal platelet count, normal prothrombin time, and increased partial thromboplastin time. The findings in this patient are most consistent with which of the following conditions?
A) Antiphospholipid antibody syndrome (RIGHT?)
B) Factor V Leiden mutation
C) Increased factor VIII (antihemophilic factor) concentration
D) Protein C deficiency (WRONG)
E) Prothrombin G20210A mutation

So, the patient has a clotting problem (DVT + miscarriage), but an increased PTT (bleeding problem) as well. I had no idea which disorder could account for both (the closest I can get is something like DIC, but that wasn’t on the list). After some Google-ing, I guess it’s probably antiphospholipid antibody syndrome. I just want someone to confirm with an explanation, if possible. I don’t think this disease is even in FA (unless I’m mistaken). My Robbins’ pathology had only one sentence on it.

Stupid NBME 13. Did so badly.

1. F. According to some sources, B2 also increases lipolysis. classic board question ambiguity.

2. C. these questions are always going after TNM staging

3. A. recurrent spontaneous aboirtions plus a lab value inc PTT --> lupus anticoagulant. also known to cause both arterial and venus thrombosis

 

[PeterParker7]

Have some questions of my own:
Section 1-6
73 yo F w/ hx of urinary frequency and urgency. Also had a3 mo history of walking, converstation, and memory difficulties. neuro exam shows normal strength and sensation. MMSE 21/30. walks with a wide based shuffling gate. CT shows enlarged ventricles. Whats the dx?
A) artherosclerosis of carotid artery
B) demetia alzheimers (im guessin its this bc of the vacuolization but didn't sit right with me because of the other sx)
C) huntington's
D) normal pressure hydrocephalus
E) parkinson (wrong- why i put this, who knows)
F) small vessel disease (felt like it could be this too)

Section 1-44
49 yo man is brought to the ED after fainting. he regained consciousness 1 min after fainting. he says he's had watery diarrhea the last 5 days which hasn't improved with fasting. he hasn't changed his diet ro traveled overseas recetnly. his BP is 90/60. flushed face, dehydration. K+ is low, glucose is 150. he is admitted adn gets fluid replacement. next day he passes a stool with a volume of 3.5:. whats the cause of his diarrhea?
A) bacterial overgrowth (wrong- i think i put this bc his blood gluc was high and thought it could relate somehow)
B) cholera
C) inactivation of lipase (no bc no food didn't fix)
D) lactose intolerance (no bc no food didn't fix)
E) VIPoma

In retrospect, I'm thinking VIPoma --> WDHA. can anyone confirm this? I just wasn't sure because I wasn't sure what 3.5L of stool is compared to your average person. It sounds high to me, but I kind of blanked on this.

2-16
a previously healthy 25 yo man is admitted for tx fo viral pneumonia. he is mechanically ventillated bc of respiratory failure due to hypoxemia. an open lung biopsy shows acut lung injury. which of the following in the biopsy most clearly suggests diffuse alveolar damage rather than bronchiolitus obliterans-organizing pneumonia?
A) alveolar hyaline membrane
B) foamy macrophages (wrong)
C) interstitial collagen deposition
D) Masson bodies
E) uniform fibroblastic proliferation

2-18
a previously healthy 6 yo girl is brought to the ED for severe ab pain, N/V that began 4 hours after attending a friend's bday party. Cake and other pastries were served at the party. She appears acutely ill and mildly dehydrated. her temp is normal, pulse 104, resp 20/min, BP 96/60. exam shows no abnormalities of the skin. bowel sound is hyperactive. which of the following is the most likely cuase of these findings?
A) bacteremia
B) enterotoxin (yeah? staph?)
C) intestinal mucosa inflammation
D) lead toxicity
E) villus atrophy (wrong)
F) viremia

 

[JasonE]

Have some questions of my own:
Section 1-6
73 yo F w/ hx of urinary frequency and urgency. Also had a3 mo history of walking, converstation, and memory difficulties. neuro exam shows normal strength and sensation. MMSE 21/30. walks with a wide based shuffling gate. CT shows enlarged ventricles. Whats the dx?
A) artherosclerosis of carotid artery
B) demetia alzheimers (im guessin its this bc of the vacuolization but didn't sit right with me because of the other sx)
C) huntington's
D) normal pressure hydrocephalus
E) parkinson (wrong- why i put this, who knows)
F) small vessel disease (felt like it could be this too)

Section 1-44
49 yo man is brought to the ED after fainting. he regained consciousness 1 min after fainting. he says he's had watery diarrhea the last 5 days which hasn't improved with fasting. he hasn't changed his diet ro traveled overseas recetnly. his BP is 90/60. flushed face, dehydration. K+ is low, glucose is 150. he is admitted adn gets fluid replacement. next day he passes a stool with a volume of 3.5:. whats the cause of his diarrhea?
A) bacterial overgrowth (wrong- i think i put this bc his blood gluc was high and thought it could relate somehow)
B) cholera
C) inactivation of lipase (no bc no food didn't fix)
D) lactose intolerance (no bc no food didn't fix)
E) VIPoma

In retrospect, I'm thinking VIPoma --> WDHA. can anyone confirm this? I just wasn't sure because I wasn't sure what 3.5L of stool is compared to your average person. It sounds high to me, but I kind of blanked on this.

2-16
a previously healthy 25 yo man is admitted for tx fo viral pneumonia. he is mechanically ventillated bc of respiratory failure due to hypoxemia. an open lung biopsy shows acut lung injury. which of the following in the biopsy most clearly suggests diffuse alveolar damage rather than bronchiolitus obliterans-organizing pneumonia?
A) alveolar hyaline membrane
B) foamy macrophages (wrong)
C) interstitial collagen deposition
D) Masson bodies
E) uniform fibroblastic proliferation

2-18
a previously healthy 6 yo girl is brought to the ED for severe ab pain, N/V that began 4 hours after attending a friend's bday party. Cake and other pastries were served at the party. She appears acutely ill and mildly dehydrated. her temp is normal, pulse 104, resp 20/min, BP 96/60. exam shows no abnormalities of the skin. bowel sound is hyperactive. which of the following is the most likely cuase of these findings?
A) bacteremia
B) enterotoxin (yeah? staph?)
C) intestinal mucosa inflammation
D) lead toxicity
E) villus atrophy (wrong)
F) viremia

1. D. classic wacky, wild, wet
2. E. didnt improve with diet so you know it wasnt something he was eating. watery and loss of K --> point to VIPoma

3. A. diffuse alveolar damage buzzword

4. B. staph aureus food poisoning (cake or potato salad). once you get this stuff down its simple. I knew it was prob staph aureus food poisioning after the second sentence

 

[PeterParker7]

hmmm, normal pressure hydrocephalus though? i thought you wouldn't see enlarged ventricles?

 

[ijn]

Have some questions of my own:
Section 1-6
73 yo F w/ hx of urinary frequency and urgency. Also had a3 mo history of walking, converstation, and memory difficulties. neuro exam shows normal strength and sensation. MMSE 21/30. walks with a wide based shuffling gate. CT shows enlarged ventricles. Whats the dx?
A) artherosclerosis of carotid artery
B) demetia alzheimers (im guessin its this bc of the vacuolization but didn't sit right with me because of the other sx)
C) huntington's
D) normal pressure hydrocephalus
E) parkinson (wrong- why i put this, who knows)
F) small vessel disease (felt like it could be this too)

Normal pressure hydrocephalus - remember Wet (urinary incontence), Wacky (dementia), Wobbly (ataxia); it's caused by stretching of the corona radiata as they transverse the wall of the lateral ventricles.

Section 1-44
49 yo man is brought to the ED after fainting. he regained consciousness 1 min after fainting. he says he's had watery diarrhea the last 5 days which hasn't improved with fasting. he hasn't changed his diet ro traveled overseas recetnly. his BP is 90/60. flushed face, dehydration. K+ is low, glucose is 150. he is admitted adn gets fluid replacement. next day he passes a stool with a volume of 3.5:. whats the cause of his diarrhea?
A) bacterial overgrowth (wrong- i think i put this bc his blood gluc was high and thought it could relate somehow)
B) cholera
C) inactivation of lipase (no bc no food didn't fix)
D) lactose intolerance (no bc no food didn't fix)
E) VIPoma

VIPoma. Patient has severe hypotension, hypokalemia from a secretory diarrhea. Hyperglycemia/insulin resistance is also associated with this tumor.

2-16
a previously healthy 25 yo man is admitted for tx fo viral pneumonia. he is mechanically ventillated bc of respiratory failure due to hypoxemia. an open lung biopsy shows acut lung injury. which of the following in the biopsy most clearly suggests diffuse alveolar damage rather than bronchiolitus obliterans-organizing pneumonia?
A) alveolar hyaline membrane
B) foamy macrophages (wrong)
C) interstitial collagen deposition
D) Masson bodies
E) uniform fibroblastic proliferation

Diffuse alveolar damage is a buzz word for alveolar hyaline membranes or ARDS.

2-18
a previously healthy 6 yo girl is brought to the ED for severe ab pain, N/V that began 4 hours after attending a friend's bday party. Cake and other pastries were served at the party. She appears acutely ill and mildly dehydrated. her temp is normal, pulse 104, resp 20/min, BP 96/60. exam shows no abnormalities of the skin. bowel sound is hyperactive. which of the following is the most likely cuase of these findings?
A) bacteremia
B) enterotoxin (yeah? staph?)
C) intestinal mucosa inflammation
D) lead toxicity
E) villus atrophy (wrong)
F) viremia

Yup, preformed S. aureus enterotoxin should present 4-6 hrs hours after ingestion. Cakes, potato salad, mayo, etc. are all big buzz words for it.

 

[ijn]

hmmm, normal pressure hydrocephalus though? i thought you wouldn't see enlarged ventricles?

No, they are enlarged. It's just that the body compensates for the high pressure since it's a chronic elevation.

 

[PeterParker7]

a couple other questions:
2-9
patient has genital herpes. which explains its longevity:
A) continuous replication in dendritic cells
B) continuous replication in epithelial cells of skin
C) continuous replication in sacral root ganglia (wrong)
D) continuous replication in T cells
E) establish latent infection in B cells (EBV?)
F) establish latent infection in circulating immune cells (CMV?)
G) establish latent infection in epithelial cells of skin
H) establish latent infection of sensory nerve cells (correct answer? for some reason i thought they were trying to refer to VZV here instead of HSV, but thinking about it, makes me feel like this is a better answer)

3-12
i know this was answered by someone before but why is it C) and not A)

3yo history of unexplained fever, lack perspiration and absence of response to noxious stimuli, and self mutilating behavior. dx is congenital insensitivity to pain with anhidrosis. genetic analysis shows missense mutation in tyrosine kinase receptor domain of TrkA gene. Assuming only a signaling defect, which of the following processes has most likely been disrupted?
A) binding of nerve factor to its receptor (why not this? its wrong though)
B) formation of Trk homodimers (tyrosine kinases are heterodimers)
C) phosphorylation of downstream molecules in response to nerve growth factors (I was hesitant to put this bc i know tyrosine kinases do trans-autophosphorylation, but i didn't want to consider that "downstream molecules", i think this was the right answer though?)
D) retrograde txp of nerve growth factor from terminals
E) synthesis of nerve growth factor

3-25
shows the pictures of the brain and gives a history of a patient with impaired sensory in her left hand.

i think i marked post central gyrus on the right side (A) but this was wrong. maybe B was actually the post central gyrus? looks that way more now to me looking at it.

4-21
the guy from japan with an ulcer in his stomach. has a history of naproxen use for OA, EtOH, smoking. which is the strongest predisposing?
A) EtOH
B) diet
C) ethnicity
D) naproxen (wrong)
E) tobacco