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Welcome to forerofore’s page.
Contributor score: 57

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 +3  (nbme21#35)
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tihs tapinet srepnest twih ropyhciomch anma,ie ti tannco be gameasnyiepmoh ucebesa it osntde ecuas aina,me ocntan be 1B2 eubceas ti lduwo be oaicmlalgtbe,s oantnc eb invmita D cuasebe ist ton ldraete to icmcpoohrhy i,anaem dan zcni is casoasetid thwi noir dcfnyeeiic ne,aima but sa a dicic.efney A ,ols leda iopnoings iitnsbih e,taoacrslefhre ti lsoko ilke an oinr ificednyce mnaaei but iencs ehrest no htroe lloaicg oonpti ti sha to eb eth aswrne heer


Subcomments ...

submitted by rockediny(10),
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reoxDt is the ctreocr seawrn e.reh Form eth oshecic ,igven rdtxoe si teh stela kllyei to aecsu atntopiscino icens sti mani naheicmms of nicoat is MDNA sanomtnaig w/meso dipoio iicttyav -- ti acn ceusa ttnpioonaics ubt eth rheto occhesi are MUCH EMRO ylekil .to sA rfo imedihdynehrpna = it is ton tiaorareppp rof eleydlr eatnptis dna it t’isn na s.esiviuttna

forerofore  diphenhydramine and other Gen 1 antihistamines are good choices for chronic cough in allergy and patients with posterior draining and post viral chronic cough (careful with the elderly). That being said, apparently it also causes constipation, so dextro is still the correct answer. +2  
passplease  Could it also be that you would not prescribe diphenyhyrdramine because they are part of the beers criteria and should be avoided in the elderly? +2  

submitted by iviax94(7),
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reeTh vhea neeb a oeclpu of qsesunoit atobu tish ipcot on the eewnr mx.sea e’vI neeb nginearws yb igatequn ioidlb ot teeeostosnrt evslle adn nuatrnclo ntreocies ot heahtl of ultasaecvur lohsiaoctres(ers or .o)tn sI htis occr?ret

liverdietrying  When you’re thinking of libido, don’t just equate it to testosterone -- make sure you’re always considering depression! Depression following stroke is common, especially with residual physical disability, so this would decrease his libido. Nocturnal erections equate to “does it actually work?” not just the vasculature but the neural input as well. For example, during prostatectomy damage to the pelvic plexus (nerves) can lead to impotence. There’s nothing to suggest that he has vascular or neurologic erectile dysfunction here, which is why his nocturnal erections are intact. +25  
_pusheen_  @liverdietrying Was it premature to assume he has trouble with erections because of neural damage from the stroke? I put low libido, low nocturnal erections. Is it because the stroke resulted in hemiparesis and not autonomic dysfunction or something like that? +5  
liverdietrying  @pusheen Correct, you won’t classically get impotence after a hemiplegic stroke. His inability to achieve an erection is much more likely to be 2/2 psychosocial effects than organic disease. If this vignette instead said that this had gotten a prostatectomy with resulting damage to the pelvic nerves that allow for erection, then it’d be a more safe choice to put no nocturnal erections. +4  
fast44  Is there a video or somewhere that explains these sexual dysfunctions? This seems to be a topic that keeps repeating on the new exams. +2  
forerofore  well, i though that because he had a stroke he would be likely to have atherosclerosis, which would keep libido high and reduce nocturnal erections, i kinda ignored the whole "he´s depressed" part of the vignette despite understanding the mechanism well. but from a clinical depression point of view, if his arteries are intact, and he is depressed, then libido would be low, and erections present at night. +4  
pg32  I can't remember exactly but I swear the question on NBME 21 the guy's wife had died as well...? Or they had gotten divorced? Either way, he had some psychological baggage as well, but his libido was still normal, and the explanation was that his testosterone would be fine regardless of his depressed mood. So I went with that logic here and missed this question. I don't understand how I am supposed to gauge someone's libido based on vague hints at their mood, especially when in one exam mood does not decrease libido and in the other it does. +  
drzed  @pg32 bro spoilers +2  

submitted by medstudied(1),
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Cna snoeeom eaespl aenlxpi hyw the aenrws to iths is niujyr to eth eroirstpo crod raehtr tnah eht rialad vren?e

pipter  because raising the arm above the shoulder suggests abduction which would mean the axillary nerve is also involved. the lesion would be more proximal. +7  
kchakhabar  I thought "up to the shoulder" is done by deltoid muscle (aka axillary nerve) and above is done by trapezius. +4  
forerofore  as far as i can find, abduction ranges of motion, per first aid are: 0-15° = supraspinatus 15-90° = Deltoid 90° = trapezius 100° (over the head) = serratus anterior in this question, they are directly telling you its not the serratus (long thoracic), because no option compromises it. Also, trapezius is innervated by cranial nerve XI, which is not a part of the brachial plexus, so, even though its worded weirdly, you can assume they are talking about deltoid disfunction. so deltoid disfunction (axillary) + radial disfunction = posterior cord +3  

submitted by pppro(23),
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isnrYiea vetshri ni lcod atemeprrtsue adn nac be btiadeno rmfo opro niaaedstt likm. h(ceCk shceytk tehs)kc

forerofore  growth in cold temperatures seems to be the method of isolation of yersinia enterocolitica +  

submitted by lamhtu(110),
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It eapspra ahtt hulaohgt INTsR are trayppoldshoeh yb ymtiiehnd nsiek,a atesnciers is ylucalta edu to astitmnuo in the latcua ersever anetrssptaicr traerh nhat ydmieihnt iaesnk ltsife.

forerofore  mutations in thymine kinase are more frequent in herpes drugs +3  
mtfp  NRTI need to be phosphorylated by HOST CELL thymidine kinase, mutation in viral kinase has no role in NRTI resistance +10  

submitted by pppro(23),
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inPatet sah PBH. ievG ahalp neo inataostng ot eudcer msooht ulsemc ntrtccaonio and eilvree iytlifcudf ratnniui.g

d_holles  lol i thought it was some kind of urinary retention problem and put H. +15  
sbryant6  How is H wrong? Oxybutinin or tolterodine treat urinary incontinence by blocking M3 muscarinic acetylcholine receptors --> urinary retention. We're just supposed to assume they are talking about BPH here because he is old? +  
jaxx  I agree. I picked "H" for that same logic. Does anyone know where we should have come to the conclusion that this was BPH? +  
forerofore  they are telling you he's having "difficulty urinating", one of the clinical criteria for BPH is reduced urinary flow rate. this is not incontinence because they are not telling you he leaks at all, just that he pees "a lot" +12  
drzed  Even if he was urinating too much, anticholinergics are contraindicated in the elderly (Beers criteria) +3  
pathogen7  @drzed tI mean techinically alpha-1 blockers are on the Criteria too ... +1  

submitted by seagull(1366),
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nmxinEgai ntiptea mfro a tuoisgorl smeilpi Beksron aBis hhwic wodul eskw eht anoputopil name fo smeru uera nrniteog wyaa mfor eth rtue euacctra enam. hTen, ezlaier recsiponi si eedtpdnen no tlaitctissa ero"P"w hhcwi is ecaiendrs easbd on the szei fo eth oiuoptnpal of eth .yudts isn(edreac reicniops = deneiarsc stliastciat e) T,herfereo na creaensi ni npauptooil of a bsdeia rupgo hiwt alde to ycrauacinc whti high .pierosinc

forerofore  to add up, the urologist himself doesn't add or remove accuracy (since this is a blood test), what decreases the accuracy is the fact that in order to be sent to a urologist you probably are sick in the first place (selection bias), so your urea nitrogen is likely to be altered. +21  
sharpscontainer  I thought of precision as more of a function of variance. Variance will decrease with a greater sample size. Had a hard time because I was thinking about those 4 darn targets (wouldn't 500 darts look more spread out than 10? but no, the variance will be better) that have been in my textbooks since 7th grade and for the first time I was asked a question about this concept only to discover that I didn't have it down as well as I assumed. +1  
peridot  @sharpscontainer I feel you, I thought the exact same thing. Looked into it a bit and I think it has something to do with the way standard error or standard deviation or something like that is calculated, but I'm still confused and too tired to dig further. Also, wanted to mention that this NBME has a similar question but instead it's about the 95% confidence interval - maybe that'll help you understand the precision thing better since the 95% confidence interval narrows with a larger sample size? So it's kinda tied to precision? +  

submitted by neonem(544),
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oarMj rksi afrtoc ofr ctriao eicstosdin is neyerspit,hon and in sith easc mhgit eb ued to naccioe ,seu hhicw useacs emdrka tsorypenihne. otesissDcni seuca a aret ni hte uitanc atinmi -- obold cna flow bdawkcasr iotn hte aeirrpcduim and asuec .apamteodn shTi aifesmnts as klesccra in the nglu ude to rpoo tfel rveciualtrn oftinucn (lsiaifcognidlitl/ lemrpob ude to p)cseoim.sonr

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9  
temmy  please why is there where a diastolic mumur? +1  
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8  
garibay92  Does anyone know why is this patient's tepmerature elevated? +1  
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1  
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +  
almondbreeze  he's only 28 - another clue for marfan? +  
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2  
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1  
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +