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NBME 21 Answers

nbme21/Block 2/Question#29 (reveal difficulty score)
A healthy 25-year-old man is participating in ...
Alanine 🔍 / 📺 / 🌳

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submitted by neonem(599),
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I ithnk you anc wnok taht tshi si a lcihamat soekrt taherr athn olaccitr caeubes a citlcroa oksret rirocgcnu nyol in hte elpatrsnotc syrug airyrmp( noessyr x)certo nda giivlnonv eht ntriee sumohunclu thiuotw ncaitfefg het rabeyn eplatrcren ygsru yaprmri( tomor oetc)xr si yvre .iluenlyk

submitted by assoplasty(100),
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tFas rae iogcneekt ece(txp dod hcani )AF, os eyth odpcure oskntee fro ryeneg putnocoidr (CltA)yco-eA trhear anht seo.lgcu If teh onqutsei akdse athw het riymrap osceur of ergyne outicdprno sa,w ti odwlu llist eb ggcenylo dna( not son,e)tke eueasbc isth is hitiwn 24 oh.urs vorewHe ferat 42 rsuho teh rnsewa lodcu be neotke eoidb.s daRsrseelg, eht oneutisq iilspecafylc dias eht pt dah a reums soceugl of ,010 cdntaiinig that ew era nikoglo fro mtehsniog thta eiospvdr a stsebruat fro iessl.ognenegouc

rigDnu resopdi of rivano,tast bstrssteau rfo nseseuggocneiol cemo mrfo tow cru:oess (1) konrdwabe of txensgii ume,scl or ()2 via a-dohncdi AF hgrtohu ln-piCpyro.ooA ane*i(lV aslo esfde nito opirynopl ,ACo utb si nto ivlndevo rnigdu atavoritsn t--;&g see e)lbow

)(1 eTh veraleat-ayupinn yeclc isrdopve iths taluieg(mn ni lmseuc + payvutre -;&-tg aailnne ;g--&t gose to vlier -&;g-t smnniraiottana ot raeauatglp-etooklht -tg-;& rpavtyue is eptaerads ofrm ngetlmiau gt-&-; tguinlaem oges to raue c,cyle vayeuprt oegs no to es)eln.niouggcseo taaeLct nac salo be dseu (tish dcolu ahev bnee a tigrh wnrsae fi ti wree .esidt)l

2() Odd ainch AsF aer osal loi,cueggcn btu isecrta cdai ovrdip(de ni eth esrnwa ceci)oh itns’ odd haic,n os ti is lyno coktegnei and nca be rdelu .tuo

tghlohAu iavlne and( roeht crbdnahe a.)a. eefd otin ACnloPryo,op-i hyet rae ont edus ni oitarnvsta asecebu snaitotavr tlsrityc ieesrl no cpiathe sung.ecoielsogne Teehs a.a. aer not emiebazlotd ni teh elrvi aceesbu the lveir aslck icrnacanhebh-d ..aa fertresasan znmeey. In rstFi dA,i ocBmhei csoi,ten udrne ,/noittaFngvaasitSr ni ohbt hte if“gntsa ets”ta hcwhi( is hinwit eht ietm erfam fo tish ,)tneiuqso ro hte antosvati“r ate”s,t othb ziteliu aciepth ngeseclnugoo.ies My suiaonstmp si taht lvaeni is dues uindgr raelurg i,eomtslmab dna nto unrgid oidrspe fo artstn.aoiv

hello  I want to re-emphasize something that @assoplasty has already stated :). The Q-stem states serum glucose = 100, and the Q asks why the patient is able to maintain normoglycemia. Therefore, you can immediately eliminate choices A and C because acetoacetate and beta-hydroxybutyrate are sources of energy during ketogenesis -- ketogenesis does not provide glucose energy sources. +11  
chandlerbas  ^ this checks out: valine and isoleucine are broken down in the muscle into branched chain 2 oxo acid via branched chain aminotransferase (reversible) then the valine and isoleucine leave the muscle and swims to the liver to be acted on by branched chain 2 oxo acid DH (irreversible). So bascially the process from taking BCAA valine and isoleucine requires 2 enzymes. the first enzyme is in the muscle, and the second enzyme is in the liver (for simplification purposes --> both organs contain both enzymes but dont have the same affinity for their substrate). source: so you're right to say that the liver +5  
toxoplasmabartonella  Thank you for such a great explanation. Isn't it glutamate instead of glutamine that combines with pyruvate in muscle to yield alanine for Cahill cycle? +1  
almondbreeze  @ toxoplasmabartonella think you are right +  
revanthshanmukh  its given that methionine histidine and valine are glucogenic AA.nso why not these form the glucose in the body first compared to alanine? +  
johnnybravo  @revanthshanmukh Although those are indeed glucogenic AA, they are also essential AA, which means they must be acquired from the diet. This patient in the stem has been fasting. FA 2020 pg 91, Lactate and Alanine help contribute to gluconeogenesis during starvation (1-3 days) +  

submitted by hayayah(1145),
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P. 91 of FA hsa a cuiqk taaienplnxo rfo sthi!

allsaycBi ocen ou'yer in a rtgsinav satte 'erthse iltsl htaecpi elesisugnnoogec onggi no as( wlle sa iugns FAF) tub the olegoussinnegec is ocnigm mrfo arplhriepe iestsu tcleaat dna enalin.a

submitted by frimmy_11(1),
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elMsuc nirtoep brksea nodw tino het miona cida lanneia ihhwc streen hilaCl Cylec ot mrof seolucg ...

volcanobuns  @frimmy_11 Why would protein break down after only 20 hours? Shouldn’t fat be the major contributor now? Also, if protein is being used, then why isn’t valine the choice? Valine is also glucogenic. +  

submitted by hello(384),
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I natw to esziaehe-rpm tigosenmh that sato@pasysl ash aaderly tetads ).:

ehT tsmQ-e tasset eurms gcoeusl = 100, dan hte Q sska wyh the eanittp is aelb ot nimatnia oro.mycaenligm

rTeer,ehfo uoy nac mtyiaeiemdl aiitelemn iohsecc A dna C aecusbe etotaaceetca nad hxybatrdoyraybutete- rae ersousc fo ngeyer gunrdi ieostgeenks -- eoetsignkes sedo not ervidpo ceoglus rgeyne uroscse.

submitted by volcanobuns(1),
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1mmy1@_ifr Why wdoul netrpoi erakb donw eaftr lyon 02 hours? uSnld’hto fta eb eht oajmr uoobrttricn ?nwo solA fi oipetnr is inbeg deus, then wyh ts’in inelva the i?cceho stI’ oasl n.ogcileugc

submitted by hello(384),
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eaPlse lpeh

hWy is anevil e?iorrncct

An annelxotipa wbloe ssay that lanvie luowd be vetodenrc ot cegluos undgri regalru sobleit?mma

earuRgl lbesmtmoai = edf eat,ts so hwy dwuol enlvai vene be edrcnoetv to eclugso?

ali_hassan  FA 2018 pg.91 - Starvation days 1 - 3: hepatic gluconeogenesis from peripheral tissue lactate and alanine. that's all +  

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