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Welcome to dr_jan_itor’s page.
Contributor score: 71

Comments ...

 +11  (nbme21#33)
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He siemss ish iefw nam, 'snti rdeya rof herto nmeo.w cPycigohsne E.D iacpshylly esh inef

 +16  (nbme21#34)
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oOtipn A is the oynl tonpoi ewerh tohb lcssume era arpt of hte ilrtoba orosA,flo. l hte lats cneteens in eth tsnoiueq esmt is a altto odmfiyer fo tahw neo dwolu exepct the nitosequ to be .giknas It si nto kangsi for you ot usmaes htta steeh leusscm heav nbee ,eedrves alp,azyrde or erernded ad.ifcl It is asnkgi uyo ot saumse tath yeht eavh ebmceo p"er"pdetan if the mleusc si aed,petrnp hnte it ntcoan ollwa hte eye to emvo onit travehwe sooniipt it loudw be ni nwhe eth lmceus is at sit tdnengheel s.inoopit So ni itsh c,eas It is eth oeifirnr surtce bnegi eeadrtppn ni a tocnnifayllu othendser ptoniiso atht si gvieepnrnt dpruaw a.egz

cjdinurdreamz  im confused...doesnt the IR make the eye look down so if its trapped then why is upward gaze affected and not downward? +
nutmeg_liver  @cjdinurdreamz it does make your eye look down, so since it's trapped in a functionally shorter position you're trapped looking down, not up. +2

 +3  (nbme20#11)
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aCn nanyeo rwsnae yhw hist eon ct'an eb .F eatB shaaeiatlm mjo?ra I asw nhnigtki seeacub fo hsi eamina nad eth "uapnroee cn"eteds hchwi nidscule the iminarnetade uopsr.anee slnesU NMBE rrwtsei nhikt atth aeoerpun noyl masen eth eons twih taerx ihetw leoepp llo

dickass  European implies northern european (they even specified the patient was a person of pallor), mediterranean descent is usually implied by country of origin or by straight-out writing 'mediterranean'. +
poisonivy  The MCV is normal, thalassemias are microcytic anemias, that hint helps to rule out the thalassemias. However, I got it wrong, not sure why it cannot be a homozygous mutation in the ankyrin gene +2
adong  @poisonivy, other commenter pointed out it's autosomal dominant so best answer would be heterozygous +

Subcomments ...

submitted by yotsubato(1030),
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yhW si ish oiibdL ?alormn 'tsI totllya epdcxtee htat eh mya vahe deucdre idlboi rtfae ihs ewfi iedd 2 yaers aog morf moes ohleirrb glnroedop lsn.slei

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  

submitted by sympathetikey(1354),
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Ieiorrnf quoeibl = pslhe oyu ookl pu ;& n.i

soAl, hyte adsi oorfl of het ,otrib os it maesk esens htat hte einrirfo eusmslc dwluo gdadema.

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 +6  
emmy2k21  Agreed. Why would a dysfunctional inferior rectus contribute to impaired upward gaze??? I eliminated that answer choice and got it wrong :( +2  
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. +14  
chandlerbas  bam! dr_jan_itor just cleaned up that confusion +1  

submitted by hayayah(1076),
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cWesakrnKi-ekfroof Dotn' ehva to be na chacilool ot get ,hits juts aslluyu si treedal ot lashimlcoo / iietahmn ce.cyfnidei

d_holles  Yeah the negative EtOH screen threw me off +3  
dr_jan_itor  Why cant it be early alzheimers and hippocampus? She could easily have been a former prominent physician and member of city council. Am i supposed to assume that simply because shes disheveled and poor hygeine that she must be an alcoholic homeless person? It also mentions no symptoms of nystagmus, ataxia, etc. +2  
kimcharito  it said broad based gait and nystagmus +9  
lilmonkey  She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment. +  
fatboyslim  @ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus." +  
suckitnbme  NBME questions also stereotype the shit out of their patients +5  

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anaCdid si a trap fo eht alonmr foral of ,iskn cludo ecsau notcnaiotmani fo a tclraen senouv eacretht. The soeqiunt tetsas atth hte ansrgmoi is lpru,ep gidb,nud ddi not desopnr ot rdoab tcsmeurp atnbioctsii aak( tehy dni'td esu zuolalofnec ro hriomnipatce .)B tas,Lly thye sdewho it teapld no oobld raga adn heter was on elsomsyhi wihch msetaienli spath t(he ylon herot belspsio nntdcreeo here.)

Ccsooyctrcpu ulyulsa ivvnosel nnmeitigsi ni moecrmimdnsoupiom p.ts . E iolc is rgam rtieregivsoopat xnh is auylsul mntsarteitd by a thorn on a sore ro esmoone hwit a rhtiyso of ndgnaiger

hungrybox  Also, the yeast form of Candida is gram (+) +30  
dr_jan_itor  I got thrown off by the part where they said "ovoid" and thought they were implying a cigar shape. I chose sporothrix for the morphology in spite of knowing that it clincally made no sense. +1  
lilmonkey  I chose S. aureus before reading the question (looks like b-hemolysis). Then I saw "budding organisms" and picked the correct one. +  
the_enigma28  I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +  
the_enigma28  I think, elliptical budding yeast forms kind of excluded cryptococcus since its almost round -_- +  
lowyield  cryptococcus also doesn't take up gram stain because the shell is too thiqq +2  

submitted by tissue creep(113),
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dhrArootp for ,rues tub rof eht ecorrd 'mI ttrype seru iths wsa unaiunhCykg ur.sVi Oynl ogt htis rfom a UorldW eistoqun sa I d'nhta esen ti unilt thne, ubt etpnlpyraa eth grlihtaraa is laelyr b,ad hiwch si hawt drew em to eth rwsne.a


meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +2  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". +21  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  
beto  it is chikungunya->fever, polyarthralgia, diffuse macular rash, dengue has retro-orbital pain mostly +1  

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t'ndo be a kdic? tno erlaly ures wath oemr hrtee is to i.t The ptntaie dotsen' vahe yan ertoh yflima os ihst amown luhsod eb eedncodris ylmfia

aesalmon  Questions like this usually hinge on asking if you're going to follow the rules or not though, obviously the one asking her to lie and say she was her sister is wrong, but the correct answer is obviously breaking the hospice center's "policy" - presumably if the physician is sending her to hospice then they don't work there so why would the Dr. be able to just tell her its fine? +5  
hungrybox  Yeah, I got this one wrong with the same logic as you, aesalmon. +1  
emmy2k21  I genuinely interpreted this question as though the two women were in a relationship because of the quotes "my close friend". I figured significant others would be allowed to visit simply. Ha seems like I'm the only one who read too far in between the lines! +8  
dr_jan_itor  @emmy2k21 I also thought the quotes implied a lesbian relationship and that the patient was afraid to share this (they grew up at a time when it was heavily stigmatized). So i was thinking, of course you and your "special friend" can stay together. I know this is not just a phase +8  
et-tu-bromocriptine  Anything particularly wrong with A (Don't worry. I'll call you right away...")? It seemed like the most professional yet considerate answer choice. Are we supposed to imply that they're partners based on those quotation marks around "close friend"? Because otherwise it seems like too casual and less professional than A, almost as if it's breaking policy. +5  
lilmonkey  I can swear that I saw this exact same question in UWORLD before. The only reason I got it right this time. +1  
docshrek  @lilmonkey can you please give the QID for the UWorld question? +2  
jakeperalta  Can someone explain to me why following hospital policy is the wrong answer? I'm so lost.And essentially how is this option any different from the last option where he asks her to say its her sister? Both go against hospital policy. Would greatly appreciate some insight yall. +  
jakeperalta  Can someone explain to me why following hospital policy is the wrong answer? I'm so lost.And essentially how is this option any different from the last option where he asks her to say its her sister? Both go against hospital policy. Would greatly appreciate some insight yall. P.s:it struck me as a romantic relationship as well, but it doesn't clear my doubt😓😭 +1  
drschmoctor  @jakeperalta Following the hospital policy is wrong because it would be cruel and unnecessarily rigid to deny a dying woman the comfort of her closest companion. Also, It would be inappropriate to ask the Pt to lie. What's the point of becoming a doctor if you have to follow some BS corporate policy instead of calling the shots and doing right by your patients? +1  
peridot  Ya kinda dumb that usually NBME usually tells us to never break the rules, yet here it's suddenly ok. But here the reason for this exception is that while only "family" is allowed, a lesbian relationship qualifies the "friend" as family (they just were never officially acknowledged as family/married due to stigma or state laws, which society recognizes today is dumb and outdated). It's a stupid technicality that her significant other isn't allowed to visit as a family member, so while we usually never want to break rules, this scenario follows the "spirit" of the rule. Plus it's a really extreme scenario where the woman is dying and just wants to spend her last moments with her loved one and it would be too cruel to deny someone that. There is no lie involved, which kinda leaves open the chance for the situation to be cleared up if worse comes to worst. This is different from E which is a straight up lie. Hope that helped. +  

submitted by usmleuser007(396),
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nCa osenome pseeal naipexl wyh 'atnc cololha eb cotrecr ni hits enttisg?

niboonsh  rhinorrhea is specific to withdrawal from opioids (aka heroin). Look at page 554 in FA2018 +12  
dr_jan_itor  what if the alcoholic just has a concurrent rhinovirus infection ;) +6  
lovebug  and FA2019 page 538. +  

submitted by whossayin(24),
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the ieqosutn wsa very polyro odewdr ni ym inon,iop ybnoyda else ?egera

niboonsh  yea it was a dumbass question, whoever is writing these questions is undoubtedly a crazy genius but homeboy (or homegirl...homeperson?) needs a few grammar lessons. +4  
yex  I agree. We know that it is a teratogen, but how does that question directs you to think about teratogenic effects instead of something physiologic? +5  
dr_jan_itor  The questions in the NBMEs by default are reject questions. So highly selective to be awful questsions. I am recieving regular heads up that the stems on the real thing lately are like 10-12 lines long. So these questions are not anywhere near like the test. NBME has f'd us good for this particular round of practice forms. +  

submitted by hayayah(1076),
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By ega 57, hte ustmhy is tlilet eorm hnat afytt e.stsui uFoatnrylt,e eht hstyum eucosdrp lal of rouy T lcesl yb hte etmi oyu rhace rpey.but yheT ear d-ilvgoeln and 'hatst yhw uyo acn osle ruyo yhtusm wotuhti irmitnaemp of uory meminu sytem.s

sweetmed  Memory T cells live for six months or less in healthy humans (Westera et al., 2013), whereas naive T cells can live for up to nine years +8  
whossayin  so the bone marrow does not take the role of the thymus? +1  
dr_jan_itor  @sweetmed, does that mean that if someone loses their thymus, they would develop imunodeficiencies appx 9 years later as the naive T cells have died off? +8  
hpsbwz  @dr_jan_itor no, because once all of the thymocytes become T-lymphocytes, they are stored in lymphoid organs until they're needed. this is why removal of the thymus in MG does not cause any immune system deficiency. +6  
peridot  @dr_jan_itor From wiki: "Thymic involution results in a decreased output of naïve T lymphocytes – mature T cells that are tolerant to self antigens, responsive to foreign antigens, but have not yet been stimulated by a foreign substance. In adults, naïve T-cells are hypothesized to be primarily maintained through homeostatic proliferation, or cell division of existing naïve T cells. Though homeostatic proliferation helps sustain TCR even with minimal to nearly absent thymic activity, it does not increase the receptor diversity." +3  

submitted by beeip(124),
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gThuoht tsih uodlw eb enohigmst arneidgrg rbcra"atii gre,s"uyr tbu o,nep utsj n"o ytrhasc dfoos, eascueb ouy're pieb.te"crd-ai

hello  Yep, seems that because the patient has prediabetes, he should avoid eating excessive starchy foods. +  
yotsubato  such a BS question IMO +6  
yotsubato  such a BS question IMO +  
breis  I put nuts thinking of "fats" and that with a bariatric surgery they may have problems with absorption.. +5  
teetime  This isn't right because the bariatric surgery will cure the prediabetes. It's dumping. +2  
dr_jan_itor  Why should he avoid eating excessive starchy foods? To avoid gaining weight? It doesn't matter what macronutrients he eats if they are calorie controlled. +1  
dhkahat  yeah but he's prediabetic. you want someone like that to shove a bunch of starch down all the time? +  

submitted by strugglebus(165),
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rllanopPoo is a ene-vneoitscl Beta kc.obrel oS uoyr RH illw cseeerda )B,(1 whcih liwl suaec a opcnteoymrsa eianrces in RT.P

home_run_ball  ^ Above is partially right: Propranolol is non-selective Beta blocker: Beta1 stimulation causes inc HR, therefore blocking it will dec HR and dec Cardiac output Beta 2 stimulation causes vasodilation, therefore blocking it will CAUSE UNOPPOSED alpha1 activation --> therefore increasing total peripheral resistance. +42  
amarousis  so why tf do we give beta blockers for hypertension -.- +6  
dr_jan_itor  I would also add that the patient was previously on an a2 inhibitor (clonidine), which he ran out of. So he is rebounding on that with upregulated a1 receptor activity. Adding labetalol would cause a greater degree of unopposed alpha, increasing tpr +1  
llamastep1  @amarousis They are used for hypertension because the hypotensive effect of the reduced CO is greater than that of the effect of the increase of TPR. Cheers. +7  
hungrybox  @dr_jan_itor Adding labetalol would not cause unopposed α1 because labetalol and carvedilol are α1 blockers in addition to being nonspecific β blockers (great name btw, I love scrubs haha) +2  
mw126  Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +  
rockodude  @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +