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@kimcharito Aortic stenosis radiates to the carotids
FA pg. 285 (2018)
Reducing acid production helps mucosa heal alot more than increasing prostaglandins. We learn about misoprostol because it can be used if you dont have anything else but you're never gonna choose it over a PPI
I think this one was pretty easy if you just know the regional anatomy. That was the only answer choice that could remotely have that presentation, so I think it was just testing your knowledge of the structures listed relative to the description.
aorta is also behind of liver...
I also didn't realize the surgeon's hands would so deep in he could touch the IVC on a Lappy....kinda eliminates the point of a Lappy....
"A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity." Exploratory laparOTOMY very different than LaparoSCOPY, which is what I think you may be confused about. One is a gaping hole from which you can observe everything, and the other uses tiny incisions and scopes. Even still, a hand port used during laparoscopy can allow for digital manipulation of organs as needed.
I dont think the physician caused the avulsion, I think it was there already and he grazed the area. Causing it to fully avulse and break what ever clotting was going on.
I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps.
I mean... couldn't increased BP during exercise worsen his MVP and give him SOB?
(by causing slight regurg)
"Lungs are clear to auscultation"
But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for?
I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts?
Just noticed that he has FHx, game changer.
clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP
shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise)
Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP.
it took me a little; the FHx really pushed me to exercise induced. I was also looking at malingering but there wasnt a real reason to push me to this (as a doctor it would be sad to be like hes faking it becasue he doesnt want to play sports with out being sure first; led me away because there wasnt enough pointing there). Also MVP could be slightly benign and is very common and usually no Sx and his lungs were clear as was rest of exam. All pushed to Asthma
I think MVP on its own shouldnt cause SoB with cough (in a question, I'm sure it could in the real world). In the world of NBME questions where you need to follow the physiology perfectly, you would need some degree of MR that lead to LV dysfunction/vol overload, and theres no pulmonary edema nor an S3 that point us towards that. Malingering would have to be faked for gain, and theres no external gain here or evidence that he's faking symptoms. You would also need to r/o physical illness before diagnosing malingering, which hasnt been done. Cold weather is certainly known for exacerbating EIA and are the exam buzzwords, but any exercise can absolutely be a trigger
Yeah the negative EtOH screen threw me off
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.
it said broad based gait and nystagmus
She is/was an alcoholic and appears pretty much homeless, just not drunk at this moment.
@ dr janitor. The question says "physical exam shows a broad-based gait and nystagmus."
NBME questions also stereotype the shit out of their patients
I don't understand the last part of this question stem though... if the mother's TSH *increases* during pregnancy? Wouldn't this further increase her (and/or the fetus's) production of T4 and thus counteract the hypothyroidism?
@neonem no. Autoimmune hypothyroidism is a destruction of the thyroid gland, and a decrease in production of T3/T4.
An increase in TSH means that there is not enough T3/T4 to inhibit TRH, and so TSH is being released to stimulate the thyroid gland.
TSH, T3, T4 and thyroglobulin cannot cross the placental barrier.
@arezpr although those hormones can't cross, the autoantibodies from Hashimoto's can
The baby has its own TSH though
TSH comes from the pituitary, and act on the thyroid. Autoantibodies attack the thyroid, so TSH doesn't work.
I think there is no goiter because the baby's thyroid gland has not fully developed and these immunogloblulins from the mother could attack the thyroid gland leading to issues with it's development.