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 -1  (nbme18#34)

This is strep pneumo, which has alpha hemolysis (green)

breis  How is this differentiated from Strep Virdans which is Optochin Resistant? Because Strep Pneumo would also be inhibited by optochin*
mjmejora  its strep viridans. Strep viridans has a "protected chin mask" and strep pneumo is "exposed" in the sketchy.

 +1  (nbme18#45)

"Despite inhibition of HMG-CoA reductase by statins, cells compensate by increasing enzyme expression several fold. However, the total body cholesterol is reduced by 20%–40% due to increased expression of LDL receptors after statin administration."


 +3  (nbme24#7)

Phase III Clinical Trial (per FA 2019, p. 256): Large number of patients randomly assigned either to the treatment under investigation or to the standard of care (or placebo).

usmile1  also just to verify, there is no such thing as phase 0 right?
madojo  Not that i know of or is in FA

 +4  (nbme24#37)

"Increased blood concentrations of T4-binding globulin: TBG is one of several proteins that transport thyroid hormones in blood, and has the highest affinity for T4 (thyroxine) of the group. Estrogens stimulate expression of TBG in liver, and the normal rise in estrogen during pregnancy induces roughly a doubling in serum TBG concentratrations."

"Increased levels of TBG lead to lowered free T4 concentrations, which results in elevated TSH secretion by the pituitary and, consequently, enhanced production and secretion of thyroid hormones. The net effect of elevated TBG synthesis is to force a new equilibrium between free and bound thyroid hormones and thus a significant increase in total T4 and T3 levels. The increased demand for thyroid hormones is reached by about 20 weeks of gestation and persists until term."


 +3  (nbme24#22)

"Innervates the muscles of the medial compartment of the thigh (obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis)."


famylife  Pics: https://www.google.com/search?rlz=1C1CHZL_enUS753US753&biw=1368&bih=809&tbm=isch&sa=1&ei=W6P6XJa3NMSQggfa35YY&q=obturator+nerve+adductors&oq=obturator+nerve+adductors&gs_l=img.3...9024.9024..9214...0.0..

 +2  (nbme24#32)

There is "a direct action of histamine on the lymphatic smooth muscle via stimulation of H1 (and in some vessels H2) receptors. H1 receptors enhance and H2 receptors slow down lymphatic pumping, the dominant effect being an increased contractile activity."


davidw  If the Infarct was on the right side they you would have a decrease in PCWP
usmile1  yes exactly. Cardiogenic shock always has decreased CO and increased SVR. PCWP is the tricky part. If its right sided, there isn't enough blood making it to the LA (which is what PCWP measures) thus PCWP would decrease. If it is left sided, as indicated in this question by the crackles in the lungs, the blood is backing up in the left side of the heart so the PCWP would go up.

 +0  (nbme24#7)

Not a full answer but it's a start (in the context of an obstruction): "Obstruction of urine flow results in an increase in hydrostatic pressures proximal to the site of obstruction. It is this buildup of pressure that leads to the accompanying pain, the distention of the collecting system in the kidney, and elevated intratubular pressures that initiate tubular dysfunction. In the first days of obstruction, the dilatation of the poorly compliant collecting system may be minimal. As the increased hydrostatic pressure is expressed in the urinary space of the glomeruli, further filtration decreases or stops completely." (Harrison's, 20e, Chapter 313)

trichotillomaniac  the key here is the term hydronephrotic kidney. anytime there is that, there is a post renal obstruction of some sort. The fact that he has progressive renal failure just contributes to the idea that his kidneys have seen damage before and are not able to withstand the pressure from the back up as well. I got tripped up on this. The important thing to note is that Hydronephrosis and dilation = back up = increased in volume pressure (hydrostatic)

 +5  (nbme24#40)

"Thyroglossal duct cysts most often present with a palpable asymptomatic midline neck mass usually below [65% of the time] the level of the hyoid bone."

"The thyroglossal tract arises from the foramen cecum at the junction of the anterior two-thirds and posterior one-third of the tongue."


dbg  Am I the only one who thought, my whole life, that it actually originates from the thyroid but just physically connected to the tongue

 +3  (nbme24#14)

opioid withdrawal sxs (FA 2019, p. 558) = sweating, dilated pupils, piloerection (“cold turkey”), rhinorrhea, lacrimation, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms)”

 +1  (nbme24#8)

"Beneficence involves balancing the benefits of treatment against the risks and costs involved, whereas non-maleficence means avoiding the causation of harm."


 +1  (nbme24#30)

To rule out SIADH type: "Serum potassium concentration generally remains unchanged. Movement of potassium from the intracellular space to the extracellular space prevents dilutional hypokalemia. As hydrogen ions move intracellularly, they are exchanged for potassium in order to maintain electroneutrality."


usmile1  Does anyone know if SIADH is associated with hypertension? I don't think it is due to the body's response of downregulating aldosterone, but if someone could verify that I would appreciate it.
sunshinesweetheart  @usmile1 pg 579 FA 2019 = BP can be normal or high in SIADH
usmlecrasherss  in SIADH GOLJAN says you have diluteonal hypokalemia

 +6  (nbme24#37)

"double-strand breaks...are caused by ionizing radiation, including gamma rays and X-rays." vs. "UV radiation causes two classes of DNA lesions: cyclobutane pyrimidine dimers (CPDs, Figure 1) and 6-4 photoproducts (6-4 PPs, Figure 2)."


 +1  (nbme24#40)

From AAFP:

"Acute respiratory distress syndrome is a manifestation of acute injury to the lung, commonly resulting from sepsis, trauma, and severe pulmonary infections. Clinically, it is characterized by dyspnea, profound hypoxemia, decreased lung compliance, and diffuse bilateral infiltrates on chest radiography...

In ARDS, the injured lung is believed to go through three phases: exudative, proliferative, and fibrotic, but the course of each phase and the overall disease progression is variable. In the exudative phase, damage to the alveolar epithelium and vascular endothelium produces leakage of water, protein, and inflammatory and red blood cells into the interstitium and alveolar lumen. These changes are induced by a complex interplay of proinflammatory and anti-inflammatory mediators."


 +1  (nbme24#30)

"An odds ratio of 1 indicates that the condition or event under study is equally likely to occur in both groups. An odds ratio greater than 1 indicates that the condition or event is more likely to occur in the first group." (https://en.wikipedia.org/wiki/Odds_ratio)

Subcomments ...

submitted by xxabi(105),

ARBs result in the following changes: increased renin, increased Ang I, increased Ang II, decreased aldosterone and unchanged bradykinin

famylife  ...and just to clarify, they directly inhibit the Ang II receptor (AT1) https://www.drugs.com/mmx/losartan-potassium.html +  

submitted by famylife(37),

"Innervates the muscles of the medial compartment of the thigh (obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis)."


famylife  Pics: https://www.google.com/search?rlz=1C1CHZL_enUS753US753&biw=1368&bih=809&tbm=isch&sa=1&ei=W6P6XJa3NMSQggfa35YY&q=obturator+nerve+adductors&oq=obturator+nerve+adductors&gs_l=img.3...9024.9024..9214...0.0.. +  

submitted by bunye(5),

Mesenchymal tissue can also undergo metaplasia.

A classic example is myositis ossificansmin which connective tissue within muscle changes to bone during healing after trauma - Pathoma Ch 1 pg 2

bunye  ossificans in which* +  
famylife  Images: https://www.google.com/search?q=myositis+ossificans&rlz=1C1CHZL_enUS753US753&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjytonS0dfiAhWMVN8KHaE2CUUQ_AUIECgB&biw=1368&bih=809#imgrc=tw9b-AqKfJOb7M: +  

lsmarshall  Rectal prolapse through posterior vagina ("rectocele"). https://www.drugs.com/cg/images/en2362586.jpg +5  
famylife  "When a rectocele becomes large, stool can become trapped within it, making it difficult to have a bowel movement or creating a sensation of incomplete evacuation. Symptoms are usually due to stool trapping, difficulty passing stool, and protrusion of the back of the vagina through the vaginal opening. During bowel movements, women with large, symptomatic rectoceles may describe the need to put their fingers into their vagina and push back toward the rectum to allow the stool to pass (“splinting”). Rectoceles are more common in women who have delivered children vaginally." https://www.fascrs.org/patients/disease-condition/pelvic-floor-dysfunction-expanded-version +6  
usmleuser007  really like the pubic hair.... +