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Comments ...

 +12  (nbme21#27)
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AF 0128 .p 096. stSecpu eraltruh njryiu if bldoo si enes at teh ertlhrau Miesmcnha fo sroptoier trealruh ujnriy = icvpel c,rutafre wihhc ew ese in stih eatp.tin hrltaUer eartianzechotit si iyellevtar

hyperfukus  thank you! +
baja_blast  Understood, but is there anything in the question that rules out BPH specifically? I honed in on the words "most likely" and saw he was 60. I guess I overthought it but I'd appreciate any insight as to what if anything in the Q makes that definitively wrong. +
daddyusmle  I think the question stem, with the trauma and fractures, points you in the direction of membranous urethral trauma. Pelvic fractures are more associated with urethra damage than prostate damage, although they're right next to each other, and I can see why someone would choose prostate hypertrophy. Also, I'm not sure if bleeding is associated with BPH. +
mumenrider4ever  FA 2020 pg. 627 +2
nio5021  could someone explain why urethral stricture is incorrect? +
nio5021  According to mayo clinic, strictures can be caused by trauma to pelvis as well. Would strictures be more likely if this patient had some sort of procedure done? +
eghafoor  @nio5021: "Trauma to the anterior urethra is often from straddle injuries. This can occur with a sharp blow to the perineum. This type of trauma can lead to scars in the urethra ("urethral stricture"). These scars can slow or block the flow of urine from the penis. Trauma to the posterior urethra almost always results from a severe injury. In males, posterior urethral trauma may tear the urethra completely away below the prostate" Source:,of%20urine%20from%20the%20penis. +
eghafoor  The key for this question was recognizing that the pelvis was fractured = unique only to posterior urethral injuries (FA 2020 p. 627), and after was to realize that you'd have an urethral disruption/tear +

 +4  (nbme21#2)
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Urdolw diQ 5341 hsa a ogod pntealnixao sa to who upryomnal fbissiro nircasees eth arldai rtaiotnc no het iwraay alwl.s

cienfuegos  I think this is it -pulmonary fibrosis increases elastic recoiland widens airway 2/2 increased outward force (radial traction) by fibrotic tissue thus decreasing airflow resistance thus supernormal expiratory flow rates (higher than nl following correction for lung volume) +3
notyasupreme  ^ Why do I feel like this is literally not english, I have no clue what's being said here. Can someone else explain it? +1

Subcomments ...

submitted by brolycow(27),
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He hsa treha rleuiaf cwihh daels to a ceeaerds ni enral odlob lwfo and renaperl etam.aizo In eneparrl zit,aomae NBrU:C rtaio si &=g;t 20; cviitnAato of eth SAAR tmeyss ude ot the eprlenar aamztioe msnae htta the cesp grva si high ta 52.01 dna eh is hgnodli toon usdomi so inrruya muodis wlli eb lwo t,2(0&l; NFaE &);t.l%1

figprincess  did you figure out the the ratio by actually divding out the numbers since the q didn't give it as a ratio? also what resource tells us what prerenal spec gravity should be? +  
brolycow  I just usually remember from class that spec grav 1.001-1.010 is considered dilute urine, and anything 1.025 and above is concentrated. For this question specifically, I think I remember there only being one option that even had the ratio >=20, all of the others were like 15 or less, so just have to rule them out. +7  
benzjonez  Very helpful video for acute kidney injury: +8  
notadoctor  Another explanation that helped me is that inability to concentrate the urine means something is wrong with the kidneys. If you have dilute urine, or the spec gravity is between 1.001-1.010 in someone with low urine output it suggests something is wrong with the concentration mechanisms of the kidney. Because this person had congestive heart failure we were already looking for something that matched up with prerenal azotemia so we can pretty much get rid of all the answer choices that suggest other azotemias. Then finally to get the precise answer I looked at the BUN/Cr ratio which you would expect to be high(>= 20). +  
mikay92  Would fully recommend the OnlineMedEd video on AKI. Goes through the differential, lab results, treatment, etc in a very clear and concise manner. +  
drdoom  repost via @benzjonez -> +  
drdoom  @mikay92 is this the OnlineMedEd video you're referring to? -> +1  
drdoom  aha! there is an updated AKI video but you need an OnlineMedEd (free) account to view it: +  
popofo  I understand that BUN:Cr > 20 if renal perfusion is repaired, but in heart failure wouldn't there be increased secretion of ANP/BNP from the atria that pushes up the sodium excretion? +  

submitted by aesalmon(83),
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anC nenyoa paxelni ywh iths is otn a riuitpyta ma?eonda Is ti ujst a lkac fo ethor tps?ommys

benzjonez  I think that they just wanted you to notice the **calcifications**. Per FA, "calcifications are common in craniopharyngiomas," whereas I don't think you'd expect to see calcifications in a prolactinoma. +21  
epr94  also the option is prolactinoma not broad pituitary calcifications and he doesnt show any specific signs of high prolactin +  
madojo  It says hes coming in for constituional delay in growth and puberty, i took this to mean that he had low LH, FSH due to decreased GnRH from the prolactinoma. Why did they have to say low-normal serum gonadotropin, why not just say normal? fck u nbme +1  
madojo  It says hes coming in for constituional delay in growth and puberty, i took this to mean that he had low LH, FSH due to decreased GnRH from the prolactinoma. Why did they have to say low-normal serum gonadotropin, why not just say normal? fck u nbme +1  
ac3  @madojo I believe since suprasellar tumors can cause a mass effect on pituitary gland to decrease gonadotropin levels. Where as prolactinoma causes a rise in prolactin which downregulates gonadotropin secretion. Please correct me if I'm wrong +1  
teepot123  fa '19 pg 516 +