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Comments ...

 +0  (nbme23#32)

I took the simplistic approach: I chose the opposite of whatever the kidney usually does and then lack of neg PTH feedback


 +0  (nbme23#22)

rheumatic hrt dz = mitral stenosis = pulmonary edema (bilateral crackles) = dyspnea


 +1  (nbme23#47)

found this super useful book on amazon about Budd-Chiari (check out the sick cover)


drdoom  welcome, O great physician of the skull and oral cavity. we revere your intricate understandings of the face, jaw, maxilla and all their tiny and hidden foramina. teach us your ways.

 +0  (nbme24#16)

Follow the Calcium and work backwards. ↓Ca means ↓ Phosphate resorption in the PCT (which pulls Ca with it)

25-hydrovitD normal b/c its unrelated to PTH.


 +0  (nbme24#23)

duct through the bucc. (you can feel it with your tongue)


 +0  (nbme24#44)

To me: this seemed more straightforward. You'd want to follow up and check Gastrin levels on a patient who previously had 4x normal.





Subcomments ...

Increased Levels of Myeloid cells ( Erythrocytosis, thrombocythemia, and granulocytosis) plus Dizziness and Headache increase the suspicion for Polycythemia vera.

Low EPO in PV due to Negative feedback on EPO release by kidney.

dentist  This is where the timing of everything in the question trips me up. FA say PV mechanism is increase EPO (2019, p299) +  


submitted by nwinkelmann(54),

Murmurs and maneuvers: 1st thought = how does it change with preload. All murmurs except HOCM, MVP, and atrial myxoma severity is directly proportional to change in preload (i.e. increased preload=worse murmur, etc.). Because of this, DDx can be narrowed down to HOCM, MVP, and atrial myxoma right away because the murmur worsened with decreased preload (i.e. standing up) when all but exceptions with improve.

Atrial myxoma = MCC primary cardiac tumor due to proliferation of connective tissue mesenchyme; a pedunculated mass connected via stalk to atrium septum that is suspended in the atrial blood volume and moves with the volume movement.

Presentation: triad of 1) mitral valve obstruction (i.e. malaise, symptoms of cardiac failure, syncope, etc.), 2) symptoms of embolism (i.e. facial and right arm hemiparesis in patient), and 3) constitutional symptoms (i.e. fever, weight loss, symptoms resembling connective tissue disease, because tumor releases IL-6). Others include neurologic symptoms, "pseudo-mitral valve disease" auscultatory findings (i.e. diastolic murmur), and atrial enlargement (which could compress underlying structures and cause symptoms also).

Not only does standing decrease preload, which means LA volume is lower so mass isn't as "suspended" but more mobile, standing also increases the downward gravitation force, which would contribute to the tumor moving towards the base of the atrial chamber, "plopping" on the mitral valve leaflets, and potentially extending through and causing a functional type of mitral stenosis (i.e. worsening diastolic murmur). This video explains it really well: https://www.youtube.com/watch?v=slIY64nViLg&t=161s

dentist  Sorry, you narrowed it down to HOCM, MVP, and LA myoxma, but I only see LA myxoma as an answer choice. Wouldn't you have been able to stop right there? +  


submitted by mousie(74),

help with this one please.... is this because he has hyperTG AND Cholesterol AND chylomicrons.. only LL deficiency would explain all of these findings? I chose LDL R deficiency because I guess I though it would cause all of them to increase but is this type of deficiency only associated with high LDL?

sympathetikey  First off, do yourself a favor and check this out - https://www.youtube.com/watch?v=NJYNf-Jcclo The LDL receptor is found on peripheral tissues. It recognizes B100 on LDL, IDL, and VLDL (secreted from the liver). Therefore, an issue with that would cause an increase in those, but mainly LDL. Since in this question we see that Triglycerides and Chylomicrons are elevated, that points towards a different problem. That problem is in the Lipoprotein Lipase receptor. This is the receptor that allows tissues to degrade TGs in Chylomicrons. So, if it's not working, you get increased TGs and Chylomicrons. Additionally, you get eruptive xanthomas, which are the yellow white papules the question refers to. +3  
davidw  There is much easier way go to page 94 in first aid. This kid has Type 1 Hyper-Chylomicronemia which is I) Increased Chylomicrons, Increase TG and Increased Cholesterol. It can be either Lipoprotein Lipase or Apolipoprotein CII Deficiency +5  
bulgaine  The video sympathetikey referred to only mentions pancreatitis in type IV but according to page 94 of FA 2019 it is also present in type I Hyper-chylomicronemia which is what the question stem is referring to with the abdominal pain, vomiting and increased amylase activity +  
dentist  thats not the only difference in that video.... +  


submitted by seagull(349),

So, T1/2-T5/6 are the sympathetic level for the heart. The stellate ganglion are cervical sympathetic ganglion. This question seems more incorrect (or a huge leap) to me. But hey, I know people will disagree.

dentist  you're right! heart rate is the only option under sympathetic control. +  


submitted by hopsalong(2),

I get this is a fluffy question and acknowledging the patient's reasons for missing insulin injections is the cuddliest, but I feel like this answer tows the line a bit. You don't want to say that missing doses is ok, but you also don't want to be mean to patient either. I thought this answer (A) was condoning her missing the injections, so I picked (C). In retrospect, I guess acknowledge means talk about/focus the conversation around.

dentist  I would say: "I understand why you are missing injections, but you're going to have a BAD TIME IF YOU KEEP MISSING INJECTIONS" +  


submitted by mousie(74),

Cholera = Fecal oral /Legionnaires = Legonalla pneumo = NO person to person only by inhalation of bacteria contaminated water /Lyme = tick bite /Meningiococcal = sharing respiratory and throat secretions (saliva or spit). Generally, it takes close (for example, coughing or kissing) or lengthy contact to spread these bacteria (CDC) /RMSF = tick bite

smc213  Also, when Meningococcal meningitis is treated ... close contacts are also treated prophylactically whereas the others typically are not. There's also a subunit vaccine for n. meningitis due to high infectivity rate especially in crowded establishments. +1  
dentist  So, Cholera is also p2p but Mening is more likely? +  


submitted by mousie(74),

My understanding if BC>AC this is abnormal = conductive hearing loss = otosclerosis VS Sensoryneural hearing loss will have normal AC>BC = loss of hair cells

dentist  VS: progressive unilateral hearing loss, doesn't affect Rinne Test, associated with NF2 and actor Mark Ruffalo Otoslcerosis is (usually....) progressive bilateral hearing loss, BC > AC. source +  


This is representative of leukoplakia, a pre-cancerous lesion of squamous cells. In order for it to spread to distant sites, it must first invade through the basement membrane/submucosa. Could be confused with oral hairy leukoplakia (which also is a white patch that classically arises on the lateral tongue). However, oral hairy leukoplakia is not pre-cancerous and is often associated with EBV infections or people that are severely immunocompromised.

hpkrazydesi  How did you know that this wasnt oral hairy leukoplakia? just from the picture? +1  
nwinkelmann  To piggyback off of @hpkrazydesi, you ruled out oral hairy leukoplakia because the patient was seeing the doctor for normal health maintenance, i.e. not immunocompromised, I'm assuming. +1  
dentist  @nwinkelmann thats correct! my time to shine. +  


Since you see vascularity that is why it is granulation tissue. Fibrous scar would be 1 month after and you wouldn't see that much blood.

dentist  The v-fib/death is an attempt to throw you off. The simple way of asking this question would have been: "18 days after an MI, you should see____?" +