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 +2  (nbme22#29)

The way I got this was first based off the MRI, it's definitely not the stomach, as it's no where near the stomach. Going off that, the duodenum comes right off the stomach, leading me to also cross that out. Then from the stem it said LEFT MIDabdominal pain, allowing me to cross out appendix (also no fever) and therefore cecum as well. Only remaining choice you're left with is jejunum!


 +3  (nbme21#13)

Omeprazole heals gastric and duodenal ulcers more effectively than misoprostol, whereas misoprostol was more effective in patients with erosions alone.

https://www.nejm.org/doi/full/10.1056/NEJM199803123381105





Subcomments ...

submitted by xxabi(91),

Stent thrombosis vs re-stenosis. Stent thrombosis is an acute occlusion of a coronary artery stent, which often results in acute coronary syndrome. Can be prevented by dual antiplatelet therapy or drug-eluting stents. Re-stenosis is the gradual narrowing of the stent lumen due to neointimal proliferation, resulting in anginal symptoms.

sunshinesweetheart  so just to clarify - it's the "symptom-free for 3 months" that rules out thrombosis? +1  
hpsbwz  It's moreso that at rest there's no changes, but during exercise there is. Like the pathophys of stable angina. +  


submitted by usmleuser007(113),

Intussusception is generally caused by a blockage in the GI tract caused by a tumor, polyp, diverticulum, or just immobility at part of the tract.

1) My thought was that the patient had a Meckel diverticulum yes it happens in 2 feet from the ileocecal valve; but that is in about %2 of the population

hpsbwz  Meckel diverticulum itself occurs in 2% of the population. Also it would present much sooner rather than in a 28 year old man. +  


submitted by chillqd(7),

The Stem is describing hemochromatosis, characterized by abnormal iron sensing and increased intestinal absorption. This increases Iron, increasing ferritin. In response, TIBC is decreased, which increases transferrin saturation as there is less circulating carrier molecules.

With excess iron in the blood, it will accumulate in tissues including the liver, skin, pancreas. Sequelae include dilated cardiomyopathy, hypogonadism, diabetes, arthropathy 2/2 calcium pyrophosphate deposition, nd Hepatocellular Carcinoma

hello  I think you made one slight mistake. TIBC = total iron binding capacity. It is synonymous with "transferrin saturation". This patient has increased transferrin saturation aka increased TIBC. The transferrin molecules are saturated -- it is incorrect to say "as transferrin saturation increases, there is less circulating carrier molecules." It is more correct to say that the amount of free (unbound) transferrin is decreased. +1  
hpsbwz  @hello Transferrin saturation and TIBC are not synonymous. Transferrin is calculated using total body iron / TIBC. While the serum iron level continues to increase, the transferrin level decreases. Thus, the amount of transferrin available to bind iron (TIBC) decreases and the amount of transferrin saturated with iron (i.e., percent transferrin saturation) increases. +  


submitted by mcl(204),

Gait problems raises suspicion for alcohol abuse or inhaled glue. However, onset of gait problems is relatively rapid (couple of months) and gait disturbance with regards to alcohol is either due to intoxication or chronic abuse. Alternative explanation available on SDN. Also see toluene toxicity on medscape.

sbryant6  I got this correct solely based on the patients demographic. Glue is cheap and easily accessible to underage populations. +  
whossayin  Kinda racist of us but that’s how I reasoned my answer too lol @sbryant6 +  
hpsbwz  how is it racist if the only thing thats given is his age lol @whossayin +2  


Legionella is common causes of pneumonia superimposed on chronic obstructive pulmonary disease.

asapdoc  Im pretty sure so is strept pneumoniae +2  
usmleuser007  COPD is also exacerbated by Viral infection: Rhinovirus, influenza, parainfluenza; and Bacterial infection: Haemophilus influenzae, Moraxella catarrhalis, Streptococcus. however, the questions gives a hint that it may be legionella = "weekend retreat" which may be associated with this infection +  
loopers  From FA 2017 pg 139: Legionnaires’ disease—severe pneumonia (often unilateral and lobar A ), fever, GI and CNS symptoms. Common in smokers and in **chronic lung disease.** +1  
kentuckyfan  I also believe that the other attendees showed signs of pontiac fever, which is another hint they tried to get at. +1  
luke.10  i did it wrong and chose influenza virus since it is most common infection in COPD but the clue in the Question is that the other attendee didnt get sick since in legionella there is no person to person transmission +  
endochondral   but in Uworld s. pneumo is one of the most common bacterial exacerbation of COPD legionella wasn't even mentioned. How do we rule out s. pneumo ? +1  
nala_ula  maybe because in children s.pneumo causes otitis media? +  
smc213  Another hint made in the Q stem is the location being rural Pennsylvania.... Legionnaires disease was first discovered by the outbreak in 1976 at a convention held in Philadelphia, Pennsylvania. Not sure why I know this fact... +  
hpsbwz  Biggest hint towards legionella to me was that they all were at a residence hall... i.e. where there'd be air conditioners and such. +1  


submitted by yotsubato(264),

"Do no harm"

Starving the baby or withholding food is doing harm. At this point you provide palliative care until the death of the baby. If the parents decide to "pull the plug" then they can do it, but as the doctor thats not your choice.

cry2mucheveryday  Why not 'give foods according to normal caloric requirement'? +5  
hpsbwz  @cry2mucheveryday because feeding to the caloric may be too much or too little for this baby. considering the baby's crying only resolves with food, if you've already reached the limit, are you just not going to feed the baby? that's how i thought of it. "maintain comfort" is the key phrase. +1  


submitted by breis(11),

Patient has Midsystolic murmur heard at the cardiac apex. there is also a LEFT ATRIAL abnormality. Echo shows LEFT ATRIUM is enlarged.

Mid systolic... enlarged left atrium...

Best choice: Mitral Regurg

hpsbwz  Why is it regurg instead of stenosis? +1  
minhphuongpnt07  Vague question requires a lot clinical reasoning. mitral regurgitation: holosystolic murmur( this cv: midsystolic), enlarged LA, LV Mitral stenosis: diastolic murmur, enlarged LA, normal LV. only best explanation I can think of: early stage Mitral regur, that's why the murmur is not holosystolic but midsystolic and LV still adequately handle the situation +1  
dickass  @hpsbwz it's regurgitation because the murmur is SYSTOLIC, when the mitral valve is not supposed to make any sound. mitral valve leaks in systole, which causes blood to back up, which causes the left atrium to work harder and eventually hypertrophy. Mitral stenosis would be a DIASTOLIC sound, which is when the left atrium normally contracts. +1  


submitted by hayayah(399),

By age 75, the thymus is little more than fatty tissue. Fortunately, the thymus produces all of your T cells by the time you reach puberty. They are long-lived and that's why you can lose your thymus without impairment of your immune system.

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 +1  
whossayin  so the bone marrow does not take the role of the thymus? +  
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? +2  
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. +1