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 +2  (nbme24#1)

I woud do a retrospective cohort here. I don't think this question is correct and provides too little information to get the correct answer. "Time efficient" is the operant word here but they simply didn't consider that retrospective cohort would be a better design here as long as the variables are coded.

sherry  I agree. I was hesitating between the two choices. I still think cohort study is better regarding the "risk". I hope this kind of questions wont pop out on the real thing.
soph  I think key here was they were measuring risk though
yex  I also chose cohort, since it is comparing a given exposure.




Subcomments ...

submitted by seagull(355),

What a terrible picture. They they covered up part of it with lines. WTF

sympathetikey  Agreed. +  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +  
catch-22  You're looking at the ventral aspect of the brainstem. +2  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +1  


submitted by seagull(355),

What a terrible picture. They they covered up part of it with lines. WTF

sympathetikey  Agreed. +  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +  
catch-22  You're looking at the ventral aspect of the brainstem. +2  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +1  


submitted by sympathetikey(260),

Mad at myself for changing my answer.

Faulty logic made me wonder if hitting your head would caused increased ICP so, like a cushing ulcer, you would get increased Vagus nerve activity and maybe bradycardia + hypotension. But I guess the RAAS system would have counteracted that and caused vasoconstriction over 24 hours, so Hypovolemic shock is definitely the best choice.

Always should go with the obvious answer :)

seagull  I had the idea that this was a neurogenic shock and increasing intracranial pressure could affect the vagus too. I think the question really wants us to go that direction. +1  
uslme123  The Cushing reflex leads to bradycardia! +  
purdude  Wait I'm confused. I thought hypovolemic shock leads to an increased SVR? +1  
littletreetrunk  apparently, there's a thing called sympathetic escape that can happen after a while (i.e. he's been out for 24 hours): Accumulation of tissue metabolic vasodilator substances impairs sympathetic-mediated vasoconstriction, which leads to loss of vascular tone, progressive hypotension and organ hypoperfusion. +  
littletreetrunk  also also if he hit his head he could have loss of sympathetic outflow from a hypoxic medulla which could lead to vasodilation, which further reduces arterial pressure, but this was a hard one for me lol. I also put increased ICP wah. +  
catch-22  Any lack of sympathetic outflow/increased vagal outflow should reduce HR, not increase it. Further, you would expect brainstem signs if there was hypoxia to the brainstem. For example, if you had damage to the solitary nucleus, you wouldn't be able to regulate your HR in response to reduced BP. Since this patient has reduced BP and increased HR, this indicates that the primary disturbance is likely the reduced BP. He's also been in a desert for 24+ hours so. +  
charcot_bouchard  In a patient who develops hypotension following high-energy trauma, neurogenic shock is a diagnosis of exclusion that is made after hypovolemic and obstructive cardiogenic shock have been ruled out! Plus Absent Bradycardia rules it out +  


submitted by sajaqua1(171),

Gynecomastia, spider angiomata, and hypogonadism (as well as palmar erythema) are all signs of excess estrogen. The liver in patients with hepatic disease is impaired and so cannot clear estrogen sufficiently. Six 12 oz beers daily (72 oz, or half a gallon) is too much, and is destroying his liver.

uslme123  No hepatosplenomegaly, ascites, or edema through me off. We that being said, I shied away from cirrhosis. I thought that he showed signed of depression, so I went with the thyroid. But who's to say he isn't injection anabolic steroids?! +  
catch-22  The principle is you can get liver dysfunction without having HSM, ascites, etc. Liver disease is on a progressive spectrum. +1  
notadoctor  He likely has hepatitis B/C given his history of intravenous drug use. I believe both can have liver dysfunction but may or may not have ascites, whereas the type of damage we would expect from alcohol that would match this presentation would also show ascites. +  
charcot_bouchard  For Ascities u need to have portal HTN. Thats a must. (unless exudative cause like Malignancy) +  


submitted by seagull(355),

What a terrible picture. They they covered up part of it with lines. WTF

sympathetikey  Agreed. +  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +  
catch-22  You're looking at the ventral aspect of the brainstem. +2  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +1  


submitted by docred123(3),

Why is the answer to this question not Adhesivie Capsultiis...

hayayah  Adhesive capsulitis causes severe restriction of both active and passive range of movement of the glenohumeral joint in all planes (especially external rotation). +4  
catch-22  Adhesive capsulitis is aka "frozen shouder" so you can expect exactly that. The entire shoulder will be hard to move in all directions. +1  
meningitis  Since it says there is NO impingement sign, it cant be rotator cuff tendinitis correct? What other signs eliminate this option? +  


submitted by seagull(355),

i'm still convinced this is irritable bowel syndrome. Change my mind.

mousie  haha I picked this too bc she's 44.... isn't celiac something that would present much younger?? but I don't think IBS would cause an iron deficiency anemia is the hint they were trying to give us. +  
sympathetikey  If it was IBS, they would have mentioned something about them having abdominal pain, different stool frequency, and then relief after defecation, me thinks. +  
aknemu  I was between celiac sprue and IBS but what pushed me towards celiac's was a few things: 1. The Iron deficency anemia (I think that would be unlikely in IBS) 2. Steatorrhea (which would also be unlikley in IBS) 3. Osteopenia- I was think vitamin D deficency 4. Lack of a psychiatric history +4  
catch-22  IBS is a diagnosis of exclusion. If you haven't excluded Celiac (and this can't be excluded based on epidemiology alone), you can't diagnose IBS. +2  


Patient has a fracture to the inferior orbit. This can dmg V2 or entrap the IR muscle. Only IR entrapment would impair vision.

nlkrueger  if this isn't a globe rupture than idk what is tbh +2  
mousie  the air in the center of the globe made me think rupture too ..... +  
sajaqua1  There may be some global rupture, but impairment of one of the ocular muscles causing diplopia would still be the best explanation for this patient's double vision. +1  
catch-22  Globe rupture leads to entrapment of the IR muscle which causes diplopia. The question is asking what is causing his visual complaints, which is diplopia, not loss of vision. +  


submitted by sajaqua1(171),

MHC I function is integral to cancer suppression. MHC I displays endogenously synthesized proteins and presents them to CD8+ T cells. The failure to display MHC I, or MHC I display of non-self (and by extension cancerous) proteins triggers a cellular immune response, leading to destruction of the cell.

The proteasome is used for the degradation of worn out, senescent, or malformed proteins. As cancer develops, more mutations lead to increased wrong proteins. Only by expression of the proteasome, or its over-expression, can these mutant proteins be degraded fast enough to not be displayed by MHC I and lead to the cell being killed. Bortezomib blocks the proteasome, so the mutant proteins are displayed on the surface, allowing the immune system to recognize and kill pathological cells.

catch-22  Another way to approach it is to think about MHC class I processing. Basically, if you inhibit the proteasome, peptides will not be generated and nothing is available to be loaded onto MHC I (remember MHC I has to be loaded before it's transported to the cell surface). Cells that don't express MHC I get killed by the natural killers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214736/ +6  
kai  "In conclusion, we have demonstrated that the proteasome inhibitor bortezomib down-regulates class I and enhances the sensitivity of myeloma to NK cell–mediated lysis" from the conclusion of the NIH paper +3