Out of the following MUSCULAR PATHOLOGIES which have and which do not have elevated CK ?

- Muscular Dystrophy
- Hypothyroid Myopathy
- Hypercortisolism Myopathy
- Statin Myopathy
- Inflammatory Myopathy (Polymyositis/Dermatomyositis)
- PolyMyalgia Rheumatica

This is a very important concept and very high likelihood of being asked.

DAILY DOSE of USMLE Correct answer is :

HIGH CK in folloiwing:

Dystrophies (Duchenne and Becker)

Inflammatory Myositis (Polymyositis & Dermatomyositis)

Hypothyroid

Statins

Normal CK in following:

Polymyalgia Rheumatica

Fibromyalgia

Corticosteroids

NBME Answer with explanation in

depth
DAILY DOSE OF USMLE 9. 2016.

Answer & Explanation:

Question analysis: 3 STEP REASONING includes seeing the clinical
features, diagnosing the disease and the final question is based on Rx, actually
specifically the drug MOA is the question asked. (MOA = Mechanism of action)

- So we have to go in this sequence: Diagnose --> Drug --> MOA (Classic USMLE
Format Multi-step reasoning)

Step 1: The vignette presents an old man (elderly = possibly immunosuppressed)

showing unilateral right sided flank pain followed by vesicles in the same area.
(that's important pain BEFORE vesicles in a dermatome UNILATERALLY. This
sequence is unique to Shingles. Overall it is easy to diagnose this particular case
as shingles as it is classic. But remember.. Before not After.. this maybe asked in
another question in a complicated way though this one is easy.) Answering Step
1: Shingles

Step 2: Whats the drug for Shingles ? Answering Step 2: -ovir group anti-virals
(Acyclovir)

Step 3: What's the mechanism of action of -ovirs ? Answering Step 3: MOA is

inhibition of DNA polymerase by chain termination.

Hence correct answer is: B: DNA Replication

------------------------------------------------------------------------------------------------
-------------

Following is a brief re-cap of the disease & Rx from all books & banks of USMLE
combined at one place (6 Qbanks,many MANY books):

VZV (HHV- 3)

Group/Sub Group: DNA virus belonging to herpes viridae family.

MORPHOLOGY: ds DNA, linear, icosahedral, with nuclear replication and are

enveloped by a membrane derived from the Nuclear membrane (NOT Cell
Membrane- remember this point. Only virus to get it from Nuclear, rest all
enveloped viruses get it from the cell membrane).

Transmission- Respiratory secretions (Remember the disease is NOT spread

primarily by touch.. touching shingles.. even rubbing yourself to is NOT the main
transmission mechanism. ) This is important as a key preventive medicine
concept arises, try to answer the question: Which is most effective way out of
following for preventing outbreak of Chickenpox: A- Gloves B-Hand washing to
prevent fomite mediated infection C-Aerosol Mask D-Destroy all mosquitoes in
the area E-Restrict mobility of the individual in a well-ventilated room

Answer: C is most effective.. while touch COULD cause disease.. it is contrary to

popular belief a not so important cause of transmission and almost all
transmission is aerosolized.

Isnt that a nifty concept ? Remember it well as preventive medicine is a recent

update to USMLE content guidelines.)

Clinical features: Multifaceted organism: - It causes PRIMARY acute attack in

in the form of Chicken Pox (Varicella). - And SECONDARY recurrence of disease
in the form of Shingles (Zoster). Hence named Varicella-Zoster (PRIMARY-
SECONDARY)
ACUTE- Chicken Pox (Varicella) : 90% cases in kids & 10% adults. More severe
in adults. Macules --> Vesicles--> Pustules eventually crusting. ALL STAGES
present at the same time. Vesicles with red base (Dew on Rose drop sign).
Umbilicated vesicle which may haemorrhage. Starts on trunk and moves to hands
and feet. Also mucous membrane and conjunctiva involved. CENTRIFUGAL
pattern. Patient infectious 1 week before and 5 days after rash appears till it
crusts. Complications- Kids: Reyes, Encephalitis (cerebellitis ataxia),
Pneumonia, Gullian-Barre syndrome, Ramsay Hunt syndrome Adults: Hepatitis,
Encephalitis , Pneumonia

CHRONIC- Herpes zoster (Shingles) which is shown in the vignette recurs in a

lot of conditions like immunosuppression which maybe transient due to stress,
menstruation, sunlight or as in this case in an elderly person. May occur in HIV
too when CD4+ count is <500 /mm3 Complication- Post Herpatic - Neuralgia
(MC)

Treatment: Acyclovir (lot of resistance..Tyrosine Kinase and DNA polymerase

mutation mediated) Valacyclovir, Famcyclovir used more. Mechanism: Acyclovir
converted by thymidine kinase to acyclovir monophosphate and by cellular
kinases to acyclovir triphosphate. This acyclovir tri phosphate gets incorporated
in the growing DNA strand by DNA polymerase & induces chain termination
because it lacks 3 OH for chain extension. Unique Property: Guanosine analogue
A/E : Crystallinuria (Prevention Hydrate) & Neurotoxic (headache, agitation,
confusion).
_______________________________________________________
_______

Other options:

A & D => Cell Wall Synthesis inhibitors: There is no group of Viral cell wall
synthesis inhibitors. Can u name the Bacterial and Fungal cell wall synthesis
inhibitors ? Fungal: ONLY Echinocandins i.e. Caspafungin group (NOT
Amphotericin B, Nystatin - they cause hole formation within PRE-formed Cell
Wall but dont affect NEW SYNTHESIS - know the difference). Azoles and
Terbinafine are considered INDIRECT cell wall synthesis inhibitors as they
decrease synthesis of Ergosterol Lanosterol which are needed in the cell wall
synthesis. Bacterial: Peptidoglycan synthesis inhibitors (Penicillins,
Cephalosporins, Carbapenems & Monobactams ) Glycopeptides (Vancomycin &
Bacitracin) Lipopeptide (Daptomycin) Mycobacterial: Isoniazid and
Ethambutol

C => DNA Topoisomerase inhibitor antibiotic is only one group:

Fluoroquinolones. Anti-cancer drugs may be Topoisomerase inhibitors too.

G => Always remember, to make Profit in exam of RIBOSOMES you have to

buy at lower price and then sell same thing at higher price. I buy AT 30 CELLS
for 50 Aminoglycosides, Tetracyclines : 30S Chloramphenicol, Erythromycin
(entire Macro group), Linezolid, Lincosamide (clindamycin group),
Streptogramins (Quini-Dalfopristins): 50S

E and F: Reverse Transcriptase & Protease Inhibitors: Anti-HIV drugs:

NRTIs - Nucloside (mainly) & Nucleotide RT Inhibitor NNRTIs - Non-nucleoside
RT Inhibitors Protease Inhibitors - (-Navir) drugs -- List is long of drugs which
fall in these groups, so see it yourself. Here we present, some points which most
will miss: - Foscarnet is also a RT inhibitor - HepC, HepB is new upcoming and
very important therapy: Anti-Hep B: (i) lamivudine, (ii) adefovir (iii) entecavir,
(iv) telbivudine and (v) tenofovir All these 5 are super-HY and all are RT
inhibitors Anti-Hep C: Sofosbuvir (RT inhibitor), Simeprevir (Protease Inhibitor)

Thoughts from Admin of NBME Explanations Initiative Team, in FAQ

(Q&A) Format. Please DO read this longish post. While the above
content is purely professional, the below should be taken in the form
of one friend talking to another:

Qs are stuff u ask us, As are what we reply !

Q1. Is this the format in which you are going to make all the content ?

A1. This is the first draft. While it is my belief that most people will find this to be
an already good enough explanation, we wish to make it GREAT not good. We
will not reveal exactly as of now but final stuff released will be made 100x better
than what you see here. This is the first publicly released version..a sneak peak of
sorts. We have better plans in the pipeline but choose not to divulge yet. What we
can say is that it will have more images..more interactive.. much better. We are
creating, and we say with all humility almost a full QBank end to end, 14 NBME,
each has 200 Qs each, 2800 answers and explanations. It is high quality stuff
repeated innumerable times and tested heavily. It will be made almost of UWorld
level quality and all totally 100% free. People since decade..maybe more are
searching.. have been wasting time on forums.. people do this when exam is
near.. It is not appropriate that the NBME should take $50-$60 and not even give
correct answer..let alone explaination. That all ends NOW. This will solve all the
problems.

Q2. Who are you ?

A2. We choose to remain anonymous. All we want is to help others. You can say:
We are Anonymous. We are Legion. We do not.. Nahnah.. nothing sinister !
Just anonymous because we wish to help others and change the system thats all.
Q3. I am scared sh*tless.. what if all this is monitored by the NBME ? What if
they report us ? What if they come to my house ? What if I go to jail ? What if
elephants could fly ? What if Trumps hair is actually a giant beaver controlling
his mind & making him a xenophobic misogynist ?.....

A3. Firstly, we want to make this clear as a glass of moonshine (btw..another high
yield moonshine is homemade alcohol which may cause various kinds of
poisoning..an important one being Methanol for your test) the reason why we
choose to remain anonymous (ah, well u do know some of our names..but still) is
because we dont want un-necessary spotlight. We think 2 steps forward. We are
pretty surecancel that.. make that we are 101% sure the work we do will create
waves. 1000s of people will know of it and even 1000s more will wonder who
these people are who created such great content and gave it away for free? People
will say: maybe fools..they made the best stuff and didnt make a penny.. people
may say maybe its not good enoughmaybe thismaybe that. We dont want
unnecessarily to be in that place where we are judged by so many people. We
wanna help. We will help. No need to know names. End of story.

Legality issue explained in depth: One of us has a relative who happens to be a

very good lawyer. The person has specialized in IP law. IP = Intellectual Property.
The following is a detailed point by point 100% proof why what we are doing is
and shall stay always legal everywhere. ALWAYS. If questioned, we are and will
go to court to defend our rights. Our original content will stay there forever.

Q4: Haha, good joke bro.. its legal then why didnt anybody do it before ? A4:
Because nobody wanted to work as hard as we did (all ppl involved > 260, some
>270) And also btw, Incorrect.. An initiative had been started by Vikas Bhushan
& Tao Lee in 1995 & 1996. In all fairness, the book was VERY VERY poorly
written. Vikas & Tao have done a good job in step 1 FA. Rest, most of their
content has not worked commercially. At times, they were able to sell not even
10-15 copies in some of their titles. Quickly following the rise of FA 25 years ago..
these 2 thought USMLE is money machine and started making spin-off first aid
books.. Total there are over 100 books made by them.. No not FA Step 1.. thats
just 1 book. 100 different titled books of FA series.. Dont believe us ? Go and see..
they do dental..pharmacy..nursing all books.. in just medical books they have >40
titles. Other fields together > 100 almost 150 books. Here is the link to the book
they wrote on NBME Explanations still posted on Amazon (even has like 2
decade old reviews), though if I were you I wouldnt buy it (actually it is not even
available..its printing is halted because of lack of sales) as it is of the old USMLE
pattern and no one wants that stuff. AMAZON LINK:
http://www.amazon.com/Underground-s... GOOGLE books:
https://books.google.co.in/books/about/Underground_Step_1_Answers.html?
id=ZLcRQgAACAAJ&redir_esc=y We saw the book a long time ago from which
this idea spurned.. the book is dog shit.. it is so bad u will wonder if its same
Vikas and Tao that made FA ? The answers are poorly written.. the explanations
are non-existant. They explain stuff in 1 line sometimes. How can u explain a
complex concept in 1-2 lines/sentences ?

Q5: But how ???? How is it possible to take NBMEs stuff and make money off it ?
A5: You need to either meet a lawyer or read the following carefully to
understand this concept. The thing that they did and which we will do is simple:
Read the explanation to that book on amazon and what we propose to do is
simply put in the preface of that book, as seen in amazon link: The stuff
provides answers to previous test questions, (but not the questions). The
crux is not to reproduce the questions. DMCA Copyright act protects original
content owners against theft of their content by way of COPYING. Meaning if
someone will not use a COPIED version of the questions, then it is not a
copyright evasion (Its in the name isnt it.. if you dont COPY then how dos
copyright apply ?). Under Federal Law, 17 U.S.C. 512, A major limitation on
copyright is that it protects only the original expression of ideas, and not the
underlying ideas themselves. To put it simply, nobody owns Septic Shock.. no
one has a copyright over Pleural Effusion and it is not breaking the law to
explain Herpes Zoster !! We will never post their original questions. We will
never post their actual stuff copy-pasted. But we have every right to explain
concepts. No one can stop another individual from posting that as it is legal.
Herpes existed long before USA did and long before USMLE did..
https://en.wikipedia.org/wiki/Herpes_simplex#History It was talked about by
the Romans. It is in Shakespears Romeo and Juliet. I sure as hell can talk about
it and explain it too.

Q6: OMG, I cant believe this ! Is it true ? A6: Yes. 100%.

Q7: You sure you gonna post it free and not make us pay ? You know good
content fetches good money right ? A7: All of those who are doing this initiative
have scored 260s and 270s. We say it with all humility, but sorry to be blunt, we
are pretty much set for life. Sure, we can make book.. maybe some people will
buy. But most will make copies. At most a few 1000 dollars will be made by us.
Now dont get us wrong. My father is not the King of England and I would love
money as much as you would. But this is not the right venue to make it. In the
US, doctors who are smart can make tons of money in practice. Why not help our
fellow colleagues and earn good wishes.. we will earn dollars and cents later for
our entire life. Why not earn peoples love today ? :-)

Q8: You are really kind hearted !! You dont want anything back ? Q8: Do 2
things for us, and dont forget if you use our content and like it. Please do these 2:
First, tell all your friends about it and make sure most number of people benefit
off this. We will be happy to see more people getting better result. Second, we
believe in change.. change is the only constant & we think differently. You can
love us or hate us but what no one will be able to do is to ignore the impact we
made.. So make use of this resource. We are writing and making videos even
after exam..many people you will see active before exam but after their work is
done no one looks back to help others. So people have been asking..my inbox was
full so i deactivated my account. People were literally i starving for this thing. As
we all know that NBME questions are like gold as they are made by USMLE
which makes NBME. Almost all past examinees will tell you its value. I wont
elaborate u see experiences yourself.. 10-15 direct repeats and 40 or so questions
based on concepts of NBME is average.

Q9: When can I get more ? I cant wait !!! Give it !!! Give it !!!!!!!!
A9: Haha...neither can we. You will get it very soon. Though please note it is a
Not For Profit Initiative and hence will take a little while. Till then invite your
friends to the page: https://www.facebook.com/NBMEExplan... Text and
material is ready. Complete version proofread will be ready soon too.