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Welcome to chandlerbas’s page.
Contributor score: 86


Comments ...

 +2  (nbme20#19)

either bladder cancer (unilateral in this case) or transitional cell carcinoma (also uni) are precipitated by smoking inhalant toxic injury. BUT what matters more than the cause is that the reader recognize that this is without a doubt

obstructive hydronephrosis with dilated pelvicalyceal system and cortex of kidney showing atrophy and thinning.

Assuming that the pt lost blood from the MVA - this would further enhance the renal ischemia (PCT and ascending LOH are both very sensitive to ischemic conditions 30 minutes of blood loss is enough to exacerbate the already ischemic conditions.


 +1  (nbme20#9)

Legend:

OB = osteoblastic

OC = osteoclastic/osteolytic

P=prostate, B=breast, K=kidney, T=thyroid, L=lung

my mneumonic: Lead Kettle

P------------B-------------K--------------T------------L

OB-------OB/OC------OC------------OC--------OC/OB

lilyo  @chandlerbas is this pneumonic in order of most common to least common, as in is prostate cancer the most common cause of metastasis to the bone regardless of wether the patient presents with osteoclastic or osteoblastic lesions? +
hello_planet  One addition: Breast cancer causes mixed metastases, whereas lung cancer causes either lytic or blastic depending on the cancer type. Small Cell Lung Cancer causes blastic lesions and Non-Small Cell Lung Cancer causes lytic lesions. First Aid 2019: pg. 224 +2

 +0  (nbme20#23)

alright lets do this. some of the comments were really well explained, however im going to try another route. lets deal with pKa since the other comments exaplained Vd well enough. kudos fellas/fellos.

first thing is you have to determine if its an acid or base. 90% of the time its going to be a weak acid, we simple dont formulate much medications as bases in general. also its sodium salt and CNS so you know it has to be phenobarbital. step (1) low pKa means acid (4-7). you must know this. (2) you must know that all acids start off neutral and then lose an ion --> becoming charged. and all bases start off charged and then lose an ion to become neutral (this is why we dont use basic drugs because this neutral charge has a high vd and deposits in tissues = bad in elderly). you want charged bc thats what is hydrophilic aka pee it out. (3) next use what i jjust said and apply it to this chart:

+2 = 99%

+1 = 90%

-1 = 10%

-2 = 1%

the first number represents the difference between pH and pKa (pKa is given by the question always), pH is what you changed when you alkalnized the urine. so for this question it would be: pH-pKa = high basic value (>7) minus pka ( weak acid 4-7).

now the second percentage represents the percentage of dissociated proton. so for an acid, they will become charged, this means that if the difference between the ph and pKa is over +1 then 90% of the acid will go from neutral to charged. if the ph is 2+ greater than pKA then 99% of the acid will have lost its proton and become charged

lets summarize this: were told its a weak acid = aka pKa between 4-7. we want to get to take the weak acid from its neutral form into a charged form to get rid of it. so we alkalanize the urine, because bases are higher pH you will get a more + number thus the weak acid will go from neutral to charged and be excreted.


 +3  (nbme20#2)

i think because they were so specific in detail for when the sx began, theyre trying to test us if we know the onset of rota vs norovirus. also if you look at the transmission of rotavirus its FO and respiratory, so unless youre playing with poop at a wedding, its much more likely food was the transmission. sketchy says anytime you touch food with your hands its noro

heres a table for reference. https://contemporaryclinic.pharmacytimes.com/journals/issue/2016/february2016/best-approaches-to-acute-gastroenteritis


 +8  (nbme20#31)

not sure if you all have seen the uworld chart Ddx for back pain but i found it really helpful. ill summarize it here: condition (key feature): degernative osteoarthritis (positional relieved with rest), radiculopathy - disc herniation(radiates to the leg aka lasegue sign), spinal stenossi(pain with standing), spondylorpathy(relieved with exercise, and ddominant at rest), spinal metastasis(constant pain, worse at night, not relieved by positional changes), vertebral osteomyelitis(focal tenderness, acute back pain, and fever), aortic dissection (severe restrosternal pain, radiating to the back)

cbreland  What page in FA is this? +

 +3  (nbme20#19)

SPOLIER ALERT for future readers, the content following may contain subjects seen in other NBMEs


 +6  (nbme20#14)

"However, in the years, the bacterial pattern of splenectomy sepsis have been changing. The most important capsulated pathogen is Streptococcus pneumoniae (Str. Pneumoniae), but Haemophilus influenza (H.Influenzae) and Neisseria meningitidis (N. meningitidis) are also significant. In a study of 1991,36 reporting 349 episodes of sepsis in patients with asplenia, 57% of infections and 59% of deaths were caused by Str. pneumoniae." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621170/

honestly i tried to find data to support E.Coli or any higher risk of gram - sepsis, but pneumo is still numero uno

fatboyslim  FA 2020 page 186: Asplenic patients (S. pneumoniae>> H. influenza > N. meningitidis) +1

 +3  (nbme20#16)

Pt 1 (takes citric acid)

Pt 2 (takes candy)

Pt 1 (2x saliva = high flow rate, 2xNaCl [irrelevant - ignore])

Pt 2 (1x saliva = low flow rate, 1xNaCL [ignore not imp])

Pt1 = citric acid stim* ductal cell to secrete intracellular ductal storage of bicarb. bicarb neutralizes citric acid. thus low bicarb.

Pt2 = low flow rate, thus more bicarb reabsorbed out of duct. thus low bicarb

why do they have the same bicarb, because low flow rate.

*via Ach signal transduction to increase intracellular ductal calcium release --> HCO3 stored inside ductal cell


 +0  (nbme20#16)

theres an association made in 2017 with trigeminal neuralgia and MS - which is what i think this pt has. key thing to note is that while all motor and sensory fibers of CN 5 enter at the level fo the pons (however some also do enter at the level of medulla and even the sc via the spinal tract of 5 to synapse with the long sensory nucleus of 5) heres the link of trigeminal neuralgia and MS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649347/


 +1  (nbme20#49)

severe hypertension leads to hyperplastic arteriolosclerosis leading to arteriolonephrosclerosis (FA'18 --pg 297)


 +3  (nbme21#47)

theres so much iron in the blood that it has to go somewhere. it goes into the cells in the body (increased ferritin) and it binds to the carrier transport protein transferrin. because it binds to all the transferrin you have low free transferrin. but your body senses the low free transferrin and goes "ok all my transferrin are full of iron I guess im ok i dont need anymore iron" so it stops making transferrin. so low transferrin or total iron binding capacity (remember this is just a fancy way of saying it doesnt want transferrin).... now %transferrin sat is just math (i hate math) its like this: iron/TIBC, we already got high iron so numerator is high, and low denominator bc like i said TIBC is low so overall your %transferrin saturation is very high. this is the best indicator for hemochromatosis


 +3  (nbme21#13)

pt sx not responsive to dietary changes or stress reduction. stress (cortisol) decreases prostaglandins 327 (roles of cortisol). so were told that shes reduced her stress so logically her cortisol would be less, disinhibiting prostaglandin production. But her Sx still persist? thats why i ruled out misoprosol. also i remember from sketchy that ppis are irreversible tbh im not really sure if my logical flow is right, but like the guy in the other comments said, omeprazole always. just like ACEi and octreotide baby


 +2  (nbme21#16)

TLDR: last sentence summarizes it

The exact mechanism underlying AVB following ASD closure remains speculative. We can hypothesize that the possible mechanism of AVB is an inflammatory response and subsequent edema as a correlative result of mechanical rubbing of the occluder against the proximal conduction system. The margins of the secundum atrial septal defect include Bachmann’s bundle, the primary path for electrical conduction from the sinoatrial node to the atrioventricular node. The atrioventricular conduction bundle, which emerges from Bachmann’s bundle in the atrioventricular node area to conduct electrical impulses to the Purkinje fibers, is especially prone to damage.

Atrioventricular Block Subsequent to Intraoperative Device Closure Atrial Septal Defect with Transthoracic Minimal Invasion; A Rare and Serious Complication https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532427/


 +0  (nbme21#12)

remember sigmoid colon has the smallest diameter (hence why Left sided CRC produces the apple core) meaning that it is prone to higher pressures in accordance to laplace' law (pressure inversely proportional to diameter) thus small diameter = high pressure = prone to diverticula formation

chandlerbas  one more thing. this question is not realistic. 5 years of constipation, with fever and chills...yet no hematochezia? ya ok there +
chandlerbas  wait never mind, the inflammation scars the vasa recta so no bleeding. thanks for coming to my ted talk +2

 +6  (nbme21#38)

The researchers found that people who participated in mentally challenging activities most often, both early and late in life, had a slower rate of decline in memory compared to those who did not engage in such activities. Even when people had plaques and tangles and other signs of damage to their brains, mental stimulation seemed to help protect memory and thinking skills, accounting for about 14 percent of the difference in decline beyond what would be expected (Prashanthi Vemuri, PhD, Elizabeth C. Mormino, PhD: “Cognitive Stimulating Activities to Keep Dementia at Bay.” Neurology, Vol 81. 2013)

also the way i see it, AD pts have problems with hippocampus (i.e. short term memory power house) so keeping notes and lists or whatevvaa might help slow their cognitive decline as theyll be keeping the hippocampus more active


 +2  (nbme21#5)

bronchus obstruction traps oxygen in alveoli no nitrogen able to enter (atmospheric air entering body (78% nitrogen and 21% oxygen, nitrogen is so important nitrogen bc it is a poorly absorbed gas and thus is in charged of keeping alveoli inflated) oxygen in the alveoli is absorbed into the blood reducing the volume of the alveoli alveolar collapse absorption atelectasis

bethune  Why is pulmonary hypertension incorrect? +
samsam3711  PEEP allows the alveoli to remain slightly open with exhalation to prevent atelectasis. Pulmonary Hypertension is going to be related to vascular changes (instead you might see shunting of blood in areas of poor ventilation) +1
drzed  Pulmonary HTN occurs because of pulmonary vessel vasoconstriction. This can occur d/t multiple factors, but one of the most important ones is hypoxic vasoconstriction that the lungs will undergo (for example, at altitude). In the setting of PEEP, you are ventilating the lungs perfectly; this allows for the pulmonary vessels to open up and not undergo vasoconstriction. Thus, you prevent pulmonary hypertension via hypoxia. +
peridot  @drzed by your logic, you're arguing for D to be the answer but the correct answer was about preventing atelectasis +
medstudent  The question is what’s key. The purpose of PEEP is to keep the airway open. The purpose of ventilation with supplemental oxygen can help with preventing pulm HTN. Could be wrong, but that’s what makes sense to me. +




Subcomments ...

submitted by jambo2222(26),
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stI’ an cor.teaoosmsa acoSmra = ehomanstgeou mset. stI’ ni eht glse so htkni how a VDT eosg to uln.g Saem edia.

tinydoc  Perfect way to remember it. Thank you! +5  
chandlerbas  Iused the mnemonic PB (lead) KeTtLe....looking at the stem it said "osteolytic mass" meaning that it has to be either Breast, Kidney, thyroid or lungs. none of the rest are options leaving lungs. but jambo2222 very noiice that works too! +1  
jajajaja  @chandlerbas I think you might be using the mneumonic backwards- PB-KTL is for primary cancers that met to bone. For example, a primary lung cancer can met to bone and cause an osteolytic lesion. But in this case the primary cancer is the osteosarcoma. Meaning that the mneumonic doesn't actually apply to this question +11  
chandlerbas  ya you're right good stuff!! I dont know why that made sense during the question...anyways to add to the other comments...osteosarcomas are aggressive and 10% metastasize to the lungs via hematogenously at the time of diagnosis. +  
mtkilimanjaro  just to add, in terms of venous circulation everything goes to heart via vena cava and then to the lungs. The only way the bone would metastasize to these other structures would be if it continued through arterial circulation without seeding, which seems unlikely. The only ones that spread to the liver are from the PORTAL venous system, aka not bone only colon etc. +  


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cznlIotoraea rqsiuree teh cciaid nremeovnnit of het scotahm ot be b.adboser aolpmOreez ihniistb eth /H++K mppu of teh omsc,hta retybhe iacrensgde the dyatcii fo hte hm.acsot So enhw teh npiaett etask rpemlzOaeo nad nlarztaoocIe ,grteetho raaotIlenzoc wtno' eb bodebsra noit eht .dbyo stT'ah why ti sha no e.tffec

tsI' mneemreocdd ot eatk scatiinmedo at saetl 2 horsu rirpo to gtniak na .atdncia

necrotizingfasciitis  Just adding support to the above explanation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671798/ +1  
pakimd  do all azoles or just itraconazole only requires an acidic environment to be absorbed? +2  
chandlerbas  just itraconazole and posaconazole +4  
lilyo  @chandlerbas, where did you find this information? I was looking over this on FA but they do not mention it and I would like a bit more information. Thanks! +1  
chandlerbas  haha no stress! the article above submitted by @necrotizingfasciitis does a descent job explaining it, however its not good enough, I looked into a bit more on uptodate but wasn't fruitful in my endeavours. goodluck! +  
haozhier  How are we supposed to know this!! It is not in UWORLD or FA right? +3  
kevin  Someone said it on here, since there was no CYP inducer of the answer choices, the only way to even think about an answer to this question was to just go with a less acidic environment from the PPI affecting absorption. It was simply the only reasonable answer choice, I don't think there's any way we were expected to know of this exact interaction prior +  


submitted by poisonivy(25),

Per UWorld; capsaicin found in chili peppers causes excessive activation of TRPV1 (transmembrane channel), which increases intracellular calcium that results in long-lasting dysfunction of nociceptive nerve fibers (defunctionalization). It also causes release and depletion of Substance P, causing at first burning and erythema but over time causes decreased pain sensation.

chandlerbas  also topical Rx for post herpetic neuralgia +  


submitted by louisville(12),
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bellMn-yeheteu adstnie efcla armse elvdree nuorumse sthpeulroni tb(u ton yan rns).mogisa gliSahel si olocrlsse whne adeinst thwi eeentylhm ;uble E loic assnti buel whti ehytlenem eubl scabeue ti msneertf .ealtcos

sympathetikey  E. coli stains green (just fyi) otherwise, perfect. +11  
chandlerbas  only E coli stains green, all other lactose fermenters stain purple/black (just fyi) otherwise, perfect. ;) FA144 bottom +3  
dmotav  I think this is actually a separate concept – E. coli stains "metallic green" on eosin methylene blue agar, which is in the E. coli sketchy and first aid. However this question is referring to the methylene blue test on a fecal smear. From what I can gather, this test will be positive (indicated by presence of neutrophils) in cases of invasive diarrhea (i.e. shigella, salmonella, enterohemorrhagic E. coli). The test will be negative (no neutrophils) in cases of diarrhea caused by toxins (cholera, enterotoxigenic E. coli, giardia, viral diarrhea). So even though E. coli can present with fecal PMNs (if it's the enterohemorrhagic type), I guess that's less likely than shigella? source: https://www.ncbi.nlm.nih.gov/pubmed/4554412 +2  


submitted by niboonsh(293),
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wwuW/ccoF/0owt=AF.eGh1:?tuystm.b/tkvhWpaqwN noiescicluhlync aulsyul hsa v afts orunitda fo otanic zcbu lzbteeiamdo yb mpalas dsrhtose.copusaieeeln ithW yaipctla sdersoecheo,iatulespn scedrdaee smtibaelmo fo cyinccnoulihsel adn uhts eacsus a lonprdoeg inrudaot of otncia of hinynulccicoesl ;-&--gt- AAPEN

chandlerbas  i love that mosquito and then SLAP +  


submitted by hayayah(990),
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eatB eocslbkr as smrrtiancatyhhi psrspseu lonrbmaa aeckpmaers yb isegacendr het lepso fo eashp 4 t;-&g- ogrnipgnlo esahp 4.

chandlerbas  piano player sliding the keys to the left ---> delays diastolic depolarization --> rate control +6  


submitted by ergogenic22(246),
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ngagi reulsst in crdiaeesn eilraart tneffssis anch(eg ni txEar rleClualc taxriMm nctospmoiio - eeasdcred ,slntaie cieedrsna agnelclo i;o)sodtenpi HIS is oelbsrnpies fro 0-6%80 of TNH asecs ni ipnesatt ;g&t .06 l,soA daceereds cnpcileoam sa a rletsu of ginga ueassc earnicsed leusp srrueesp

rio19111  why not dev. of coronary atherosclerosis? +1  
pakimd  @rio19111 i think the Q stem is asking in absence of any lesions of blood vessels; the number and severity of which increase with age. So with normal aging SBP should increase in isolation which may then result in the development of coronary atherosclerosis- if that makes sense +1  
chandlerbas  aging causes decreased compliance in large arteries: (1) accumulation of collagen and calcium (2) degraded elastin and large arteries accumulation and it also may have something to do with lipofuschin +1  


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teIozcroanal qsrrueie the icadci vrnnnimeeot fo hte hcmtsao to be db.sbaore loOrezpeam nihistbi het H+K+/ pupm of teh tsaho,cm eertyhb cgiaeesnrd teh idtcyia of hte .aotmsch oS ewnh het petaint etkas ezlOemrapo nad atzlnorocIea hrot,eegt zealroIcaton w'ton be bosedrab into the oy.bd s'hTat ywh ti has no ffetec.

'Its rdnceedmmeo ot eakt aitndcsemio at eatls 2 rosuh rorip ot tnigka na .tdcinaa

necrotizingfasciitis  Just adding support to the above explanation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671798/ +1  
pakimd  do all azoles or just itraconazole only requires an acidic environment to be absorbed? +2  
chandlerbas  just itraconazole and posaconazole +4  
lilyo  @chandlerbas, where did you find this information? I was looking over this on FA but they do not mention it and I would like a bit more information. Thanks! +1  
chandlerbas  haha no stress! the article above submitted by @necrotizingfasciitis does a descent job explaining it, however its not good enough, I looked into a bit more on uptodate but wasn't fruitful in my endeavours. goodluck! +  
haozhier  How are we supposed to know this!! It is not in UWORLD or FA right? +3  
kevin  Someone said it on here, since there was no CYP inducer of the answer choices, the only way to even think about an answer to this question was to just go with a less acidic environment from the PPI affecting absorption. It was simply the only reasonable answer choice, I don't think there's any way we were expected to know of this exact interaction prior +  


submitted by hayayah(990),
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aCieatpt dan lteuan rae ni eth trceen fo hte pal.m Catitaep is ont an ,nopito os lunaet is eht a.wenrs

ainsiltocDo fo luneat mya seuca atuec ctenaln aulrp oyrn.msed

yotsubato  Lunate is the only carpal bone that is frequently dislocated. Scaphoid is frequently fractured. Hook of hamate is also frequently fractured. +3  
redvelvet  and also point tenderness in the anatomical snuffbox may indicate a scaphoid fracture. +3  
chandlerbas  yes lunate is the most common dislunated carpal bone ;) +4  
almondbreeze  FA 2019 pg. 439 : dislocation of lunate may cause acute carpal tunnel syndrome +  


submitted by dickass(78),

Got this one wrong because of those 2 unaffected children. Here's the explanation from FA pg 59:

Mitochondrial inheritance - Transmitted only through the mother. All offspring of affected females may show signs of disease.

Variable expression in a population or even within a family due to heteroplasmy.

Heteroplasmy basically means that multiple mitochondria are transmitted to each offspring. Their ratio may change at each generation, and cause more severe or less severe disease, even within the same family.

Those unaffected dudes lucked out.

dickass  That'll teach me not to skim FA, you really gotta look up the words you don't know. +  
chandlerbas  heteroplasmy is a fancy way of saying variable expressivity just specific to mitochondrial diseases i do declare +  


submitted by strugglebus(153),
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roeheNw have I eneb labe to ifnd why hte lehl isth is a hin.tg

yotsubato  Its not in FA, Sketchy, or Pathoma, or U world. I knew it wasnt cancer because its bilateral. And Diabetes made no sense to me. So I just threw down Drug effect and walked away. +6  
breis  same^^^ +  
feliperamirez  The only possible explanation I think is that she was under a K sparing diuretic, such as spironolactone (which would lead to gynecomastia). +  
chandlerbas  you had me at its not in sketchy ;) +  


submitted by nuts4med(6),
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Aoynne eavh an edai hwy eht ceedesdra eralitra 2O ntsaiurtoa si rceiot?ncr mAssungi esh ahs plum amede isnec hse sha LE ,eemad touw'dln a lower O2 tas be eptcxdee ot?o

haliburton  I believe there would be no decrease in O2 saturation because oxygenated blood (high pressure) is shunted into deoxygenated circuit. As long as the lungs can keep up, this should increase venous oxygenation on average. +6  
hungrybox  ty both of you for this, was wondering the same thing +  
coxsack  O2 sat won’t change b/c you’re not adding deoxygenated blood to the arterial side. You’re just taking arterial blood and putting it into venous blood. Same reason why L->R cardiac shunts don’t decrease O2 sat (while in contrast, a R->L shunt would). +4  
hungrybox  just realized: the high pressure of the arterial system keeps out low-pressure venous blood in an AV fistula (probably obvious to most ppl but it was a eureka moment for me lol) +2  
chandlerbas  ya you wont have decreased arterial O2 sat because oxygenation of blood is perfusion limited (FA19 --654) therefore oxygenation of the blood happens within the first .3seconds of entering the pulmonary capillary that you could even handle having more deoxygenated blood enter +  


submitted by nwinkelmann(260),
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So I elookd inot htsi rhrteuf too sucaeeb I reyptt hucm konw gintnoh utboa teh mkae up fo see.mn Fomr eht rhrescea I u,ndof sa sa tdtsea blwoe by ,oy ruoftsce is hte stmo atimoptnr tusnntoeitc of ensem ni esrtm ro psmer f.cnunoit wleBo si ornmtfiinoa I nfuod ot srddase teh hreot swrane ichco.se

Zinc eicyecndfi (ni s)uem,r per AF, sah eebn itapedlcim in eldyaed uodwn ,ehiagnl essdsurpep iumynmti, meal sadyomng,hopi rdaecedse atdul iarh ,lxra(ylia li,cfaa b,)upci suisedy,ag ia,onasm imsarrmotitceda opiteernatcah eecftd( ni aiisltnnte znic )tbosn,iapor and amy spioeesrdp ot hlcacoloi rhcsroiis. FA ntdid' fscepiy hte eleslv ni eht snmee, btu pre het oblwe aeitc,lr emnilsa cnzi nceotnt aws udnof to evha rno rilaetoorcn ot e/eensmspmr clietve/t.ievc/layt I d'otn knwo fi we're suseoppd ot nkow tt,ah but own I o,d ll.o .u3t//wc/nvwigt.blp75nhsniodew7:./30hp5bmm..

As orhuynbgx deenotm,in lmnseileu si ylno dntmeieon noec in FA sa a eramtentt orf aen,it os I olkedo noti it rte.fuhr nmeueSli is a entntoc fo sneme, tbu svelle vyar so cmhu thta ti ersvse on rcigposnot llaccni vclaereen to ttrf,niieily per tshi crtli:ae p/.glbs32mmtv:hwonwt//2u0iinhbedw51..3pcn./.

oT reul uot lla of teh nrsswea e(abescu I tdd'in erlaly oknw annihgyt ubota eth qaytuli of en,)sme I noduf sith yB" istist-stcta, eehrt swa no nitagiscinf rcenfidefe ni het emesn aN noatetonrncic gonma eht rnftefedi orsupg 7( srougp atlot esadb on spmer nct,uo) icntgadnii het asntifniiingc role fo Na ni spemr tyiit"..olm buvgp.p.ntwdoent522m:m./hic7w1/b1snl.//ihw.

ylFil,na I 'odnt tknhi the aa5hpl- esdrueact emnezy si tlculyaa in me,sne but I uldco be nw.gro eEhirt ,ayw it tunlw'do eb abamylronl delvteea or lwo if eth essoerttoetn leelvs aer .lmrnoa

bartolomoose  as per goljan, selenium is involved in glutathione peroxidase +  
chandlerbas  selenium has a role in glutathione peroxidase. excess selenium = garlic breath, hair loss, and nail changes, might see peripheral neuropathy. deficiency (pt on TPN) = dilated cardiomyopathy +  
chandlerbas  also zinc aids in sperm motility https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773819/ thats why i chose zinc but whateverrr im over it +  


submitted by nwinkelmann(260),
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oS I okeldo nito shit urhtrfe too cuasebe I tyrept much onwk nthonig touba het emak up of snm.ee rmoF eth ercserah I donuf, as as tedsat owelb yb yo, useoftcr is eth tosm ipntmarot ttetiucosnn of meens ni rstem or epmsr tfn.ociun olBwe is tinmafinroo I nufod to aesddsr teh otreh rnawes o.ieschc

icZn neidfyeicc n(i ms,r)eu per F,A sha eneb aplcmtidie ni adlydee onwud eaingl,h rseudsppse m,nyiutmi male ysdhmao,pgnio cdeedaser utlda raih ,ay(lilarx i,fclaa ,upib)c dugsia,esy niomaas, rtdamerioiacmst noereapiattch cf(dete in nnaiesitlt nzci isb,ponota)r dan yma edsesripop to iclohalco sir.hrocsi AF ditnd' cpfsyei the lselev in eth senme, btu epr eth webol ,tceirla ianeslm znic octennt swa nfuod to eahv ron tnielroarco to sr/mseeempn l/iaveltce.tctievy/ I 'tond owkn if wre'e sspuoepd ot wkno ta,ht tbu onw I ,od oll. 3tcsio.3/pblvnt7hb.dp/m7nim.w0/g55enuw.h/w:.

As hnbxgoruy t,eomendin lilnmeues is onyl nendtoime cneo in AF as a rtentatem rfo aei,tn so I ekodlo onit ti rhtrfu.e uSiemeln is a entcton fo e,emsn ubt lsvlee yrav so cuhm ttah it essrev on poonsgtcir cilclan eceaenrlv ot y,ritlteifni rep hsti c:reailt pwli/n/v0othdbw5gs.uh12.c.wei3.:2m/pt/nb3mn.

oT reul otu all fo eht wsrsaen ecsbua(e I nd'dti lylaer nkwo tygnhain bauot the autyliq fo ,se)men I fdonu stih "yB tsasci-stit,t erhte swa no acntisigifn rdceeefnfi in teh ensme Na nrnoaeitcocnt namgo hte ifdtnefre rgoups 7( oprugs oltat absed no rmeps nouc,)t idtigncain het siiifgntnaicn olre fo aN ni esmrp y"ottim..li ntth.2/m.o:sib2nhwu..c/g7vilw/nmp11p/w5edb.

ln,ayiFl I do'tn inthk hte -halap5 eteadcusr zmneye si yualclat in emse,n tub I ucodl eb wo.gnr Erthie ay,w ti olu'tndw be aayllobmrn lveedtea ro olw fi the oesnetrttseo llesev era roln.am

bartolomoose  as per goljan, selenium is involved in glutathione peroxidase +  
chandlerbas  selenium has a role in glutathione peroxidase. excess selenium = garlic breath, hair loss, and nail changes, might see peripheral neuropathy. deficiency (pt on TPN) = dilated cardiomyopathy +  
chandlerbas  also zinc aids in sperm motility https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773819/ thats why i chose zinc but whateverrr im over it +  


submitted by yo(54),
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eerhty' tkaginl tauob a nsolpaerlen snhtu euecodrrp

eninltt-nlreyaa//phtrtosus/o-:stre-dhac./tllh.m/edlpinaiclhcsmntaetves4e9ng05l

hungrybox  be honest did u know that before looking it up +8  
meningitis  @hungry, because you didn't know it, doesn't mean he didn't. This is a forum for answering questions and helping out, not dissing or showing off. Grow up before becoming a doctor. +14  
sympathetikey  Relax @meningitis. Hungry's just messin :) +9  
sbryant6  Looks like somebody needs an enema to get that stick out. +1  
chandlerbas  ya'll are too TP/(TP+FN) lol +7  


submitted by sympathetikey(999),
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rinrIfeo eubiolq = sphle you olok up &;pma n.i

l,sAo ethy sdai oorfl of the ,oritb so it kmesa esesn htat eht rneiorfi seculsm wdoul .geamadd

sahusema  I know you're right. I was just so uncomfortable picking an answer with "inferior rectus" because damage to the inferior rectus does nothing to explain the clinical findings of impaired upward gaze. Unless the muscle is physically stuck and can't relax or something +5  
emmy2k21  Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :( +1  
dr_jan_itor  in the last sentence it asks you to assume an "entrapment", so it is actually the inferior rectus which is the cause of the upward gaze palsy. The entrapped muscle is functionally trapped in it's shortened position, thereby not allowing the orbit to gaze upward. +13  
chandlerbas  bam! dr_jan_itor just cleaned up that confusion +1  


submitted by chandlerbas(86),

remember sigmoid colon has the smallest diameter (hence why Left sided CRC produces the apple core) meaning that it is prone to higher pressures in accordance to laplace' law (pressure inversely proportional to diameter) thus small diameter = high pressure = prone to diverticula formation

chandlerbas  one more thing. this question is not realistic. 5 years of constipation, with fever and chills...yet no hematochezia? ya ok there +  
chandlerbas  wait never mind, the inflammation scars the vasa recta so no bleeding. thanks for coming to my ted talk +2  


submitted by chandlerbas(86),

remember sigmoid colon has the smallest diameter (hence why Left sided CRC produces the apple core) meaning that it is prone to higher pressures in accordance to laplace' law (pressure inversely proportional to diameter) thus small diameter = high pressure = prone to diverticula formation

chandlerbas  one more thing. this question is not realistic. 5 years of constipation, with fever and chills...yet no hematochezia? ya ok there +  
chandlerbas  wait never mind, the inflammation scars the vasa recta so no bleeding. thanks for coming to my ted talk +2  


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agruullIrrrye luegrrIra hrthym = ffAibA ib ;g-&t- tisass fo olbod ni teh Heart gt;--&- obuhmTsr oarnmifot bmTuhosr iwll eilombze to teh )ileylk( het atpeloipl errtya eaidlng ot cteau ibml emiaschi

194orbust  why would an embolectomy be favored over clopidogrel? +2  
194orbust  oh nvm......it's bc clopidogrel won't bust a clot, just prevents them from forming. +16  
chandlerbas  also the way i see it is the hommie has so much pain as indicated by "sudden onset of severe pain" so you want something fast and effective. surgery time! grab my scalpel! drugs could be indicated but arent an option even then heparin takes 20 to 60 minutes to work so +2  


submitted by neonem(514),
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isTh is a pspmtatruo mood auecbtdnsir, a ettrpy mcmoon rodrsied tath ahs to evha na eostn nhitiw 4 skwee fo erivldey ot eb reetdm sa cuh.s soamtpPrut besul is hte stmo ilm,d iwht a -%0558 ciedncein trea p(er AF 1802,) asluluy lsresoev nhiwti 10 syda nad ttneamret si noyl svieuoptrp but dene ot lufpo-lwo to assses orf ssioelbp rtpstoupma sep.nrsdoie tpPtmouars pesoneidsr = 501-%1 ae,rt edzrecritcaah by srseepdde f,eacft yaetn,ix orop neocnionrtcat orf traeerg ntha 2 wekes dan sneed ot be dettaer /w CTB + R.SSI I ihntk the estoqnui is gtngite ta negcrnsei rof sith nad a atlnoiypelt roem atocblrmiep opaccol,nmiti mapoutrspt pi.hcyosss

thisisfine   Found this difficult because FA characterizes "thoughts of harming baby or self" as postpartum psychosis - which is super rare, and doesn't fit this case. Also, CBT is first line treatment for postpartum depression - so I still like the offer to refer to a therapist as the best choice. +9  
d_holles  Same @thisisfine. +2  
chandlerbas  i see what youre saying but we should make sure that the mother is alive for us to refer to a therapist. remember if shes willing to harm herself most likely also willing to harm the the little cutie baby....so asking for suicidal thoughts screens for progression to post partum psychosis with the aim to prevent the sentinel event: harm to the baby +  


submitted by assoplasty(88),
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Fats rae inceeoktg pxe(etc dod cnhai )F,A os teyh ercpdou toenkes ofr yernge oonitrcupd AoyCtle()-cA ertrah ntah u.clgeso If eth nquoiets dseak hwat teh yiprarm usorce of greney punioodtcr s,aw it douwl llist eb ceglnyog (nad not eent,os)k ebesuac htis is wiihtn 42 rus.ho evwoeHr eaftr 24 husor eth nswear dlcou eb enoekt i.obdes sesgeraRld, het oitnsequ lafiepiclcsy sida het pt ahd a seurm gsecoul fo 0,01 gtinaiicdn tath ew are oligonk rof moenhgsit htta doerspiv a stetrbasu rof oenelgns.cesuoig

giuDrn opiserd fo tvira,aotsn sertsusabt rfo gcsnleeoisegoun moec romf wto seocsr:u )(1 kbwnaored of niexgist ,ecslum or 2)( aiv ca-idnodh AF gthoruh yiA-oopClr.opn nl(ei*aV lsoa fdese oitn ponyprlio ,CoA ubt is not eodlnvvi nirgud svraoinatt ;-gt-& ese wboe)l

1)( ehT aup-eeivtayrnnal cyelc vrdseiop htis g(eatuimln ni selmuc + veuarpty -;gt-& aalenin -gt;-& goes ot rielv &tg;-- itonsatnraanim ot ouapl-hteatgtraleok -g;&t- taveypru is dsperaaet mfor enmtlaigu ;g--&t negmtuail geso to erua ,yccle rtupeayv goes on to lenue.oe)cssngogi aattLec can alos be deus is(ht oducl vaeh eben a rihgt awnsre if ti erew .t)lieds

2)( Odd ianhc sAF ear aosl gcc,iulngeo tub etascir icda dorv(pdei in eht srwaen cech)oi st’in dod anhi,c so it si lony keeincotg adn can eb urlde t.ou

lthhAgou liaevn nd(a rhote ecradbnh a.a). eefd tino Coolyo-,PpnAir htey rea ton duse in antitvasro abecseu ntsrtioaav csttlryi eeslir no cteaphi soleoe.encisungg heTes ..aa are ton zeletmobida ni eth eivrl cesbeau eth evirl aklcs -hnbdircheaanc .a.a anrsesaterf nzemey. In isFrt Aid, imchoeB ncstieo, duenr FoatviS,siattgnr/na ni bhto hte nfat“gsi ”ttaes chihw( si itinwh the tiem arfme fo ihst )us,inteoq ro hte vt“sanoirta ”ttea,s tohb zieilut etphaci uoslngeocsegnie. yM ssiaonpmtu si that nvalie si sdue gundri realgur bsaieotm,ml nad otn ngruid rseoipd fo rtaavo.ntis

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. +4  
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: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1147506/?page=4 so you're right to say that the liver +4  
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 +  


submitted by jambo2222(26),
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stI’ an aos.ooctearms Scmroaa = ngomeueotash .semt I’st ni hte elsg so nhkti who a DVT esog ot lg.un aSem .daie

tinydoc  Perfect way to remember it. Thank you! +5  
chandlerbas  Iused the mnemonic PB (lead) KeTtLe....looking at the stem it said "osteolytic mass" meaning that it has to be either Breast, Kidney, thyroid or lungs. none of the rest are options leaving lungs. but jambo2222 very noiice that works too! +1  
jajajaja  @chandlerbas I think you might be using the mneumonic backwards- PB-KTL is for primary cancers that met to bone. For example, a primary lung cancer can met to bone and cause an osteolytic lesion. But in this case the primary cancer is the osteosarcoma. Meaning that the mneumonic doesn't actually apply to this question +11  
chandlerbas  ya you're right good stuff!! I dont know why that made sense during the question...anyways to add to the other comments...osteosarcomas are aggressive and 10% metastasize to the lungs via hematogenously at the time of diagnosis. +  
mtkilimanjaro  just to add, in terms of venous circulation everything goes to heart via vena cava and then to the lungs. The only way the bone would metastasize to these other structures would be if it continued through arterial circulation without seeding, which seems unlikely. The only ones that spread to the liver are from the PORTAL venous system, aka not bone only colon etc. +  


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t'ond ortfge utabo eth gM !oklcb . . . . . .



submitted by tinydoc(197),
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ptuoahircNe inPa reaft toesrk is nreatlc Psot sortke anip yrndSoem

eaucds by lotaacrtaerln mitalach nolessi

g.P 405 FA19

chandlerbas  agreed! more specifically damage to the VPL +5  
docshrek  Pg. 403 FA 19. +  
baja_blast  Both commenters above got the page wrong; it's FA 2019 p. 503. +3  
teepot123  looooool ^ what were the odd of both being wrong +  
mumenrider4ever  Pg. 515 FA 2020 +  
bbr  503 in 2019 Interesting that its seen in 10% of strokes. Starts with allodynia ---> neuropathic pain. +