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Welcome to maxillarythirdmolar’s page.
Contributor score: 37


Comments ...

 +6  (nbme16#11)
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oYu hlsudo be iknghitn fo msgtohnei ilke uot.ncccsrEoe hyTe adh a UG edoercrup nad sseebuunqt dcairac s.sueis

eWhn I haer ftos ,S1 i inkht that teh aenittp smtu ehva ahd a uises htiw hte iclgsno fo triehe eth iarmlt or spiuctird v.lesav ynglaiP d,dso tish udohls eb the rlimta vvale. oYu aslo reeh an eyrla salcdotii umu,mrr os uyo ihgmt be ngiinkht vmuole evloaodr )S.(3

baja_blast  You're almost certainly right that it's mitral valve endocarditis. The murmur is accentuated by Expiration, consistent with lEft-sided murmurs. On the other hand, rIght-sided murmurs are accentuated by Inspiration. Note the capital letters for a handy trick. God Bless Dr. Jason Ryan. +7

 -1  (nbme23#33)
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Btse ocnemtm i ared was ot atert this liek 'sit a .mPIoVa oYu ouldw tge lal trehe mlcellotteceo/ireatyb nesrcu.tidbas

i0ob//b6/g9nKtol5sw:.i8n7stNkpvhc/.nh/om.w.Bw


 +2  (nbme23#36)
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eylLik na inithnoiib of loxe.2hydsray-1 shiT si eth otms ocomnm fo hte ogaltcnnei adnaelr saahelirsppy. nesPtesr ni niafync ro dodhlchi.o

otArneh mmystpo hyet may heav htta vI'e seen ndroua is on!igi!vtm koTo me a liewh ot fdin ti, btu ehyt rea aslt tinwgas yb haingv no asltroenoe,d so teh sosl fo octreetylsle is icnagsu cdearesin C.PI


 +2  (nbme23#42)
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Teh tienqosu yass thye 'dnot psrnosed to acstdian ENTH akss hhwci yuo to eitdfnyi whcih drgu is eth toms icefeeftv at spgiussenpr dcia r,onutoicpd TON htwa het mtso efevifcte ncadita i.s The wresan si 'sIP.P

I will ay,s ehow,ver I wsa nikloog orf hitsgmnoe kile doeiecor.tt

drdoom  lucid. nice catch. +1
maddy1994  WHY not blockage of h2 receptors +4
krewfoo99  @maddy1994. PPI are more effective than H2 blockers in suppression of gastric acid +1

 -2  (nbme23#12)
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AF 9,1 .pg 035 - yaM ese ralMit iaurgrtoegint eud ot peidamir tilmra eavlv rco.usle

I yaawsl idfn it taioptmrn ot ememrbre tath cnoe uyo teg agoypolth swheeemor ni hte ,taehr ouy can pcteex oapgoytlh eerverewyh enhbid ,it orev .meit

So in siht csea uoy tstra twhi HMC g-t&; rMtail rgurge ;-&tg AL ilnitado ;g&t- Abi.f -&t;g ALV/L efirual -g&;t mulP maeed gt&;- FRH ;&tg- ect.

Is't swalay a ermatt fo .imet

mario  wrong q bro @ maxillarythirdmolar +
usmile1  nope right question. he just went even deeper into the answer. +

 +4  (nbme21#50)
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oLl hhhu laso eht iosacdph is rayietlll rcudteafr ni het -ryaX


 +1  (nbme21#39)
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m'I usre st'i rtdleae to eht ttcaiaginv etecff fo oliCrsot on heamns,enfshtpreeryannNaihe-atlm-yellot iortcnengv NE ot i.pE oudnsS lkei a gssitcierny thgni ot m.e .(3F)8A

kevin  It's permissive because without cortisol Epi wouldn't be able to attain its full effect +

 +0  (nbme20#25)
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Wreeh sode eth orle fo 1B astolimntui of SARA moec ntoi ist?h nldtou'W het B1 taonci auces erescade ARS?A hTta eibng sai,d I acn alos dtusenanrd fi 'tasht a nolg emtr gitnh nad hist si a eosnuqit tuoab hte emamditie ?e.fe.tsf.c





Subcomments ...

submitted by usmleuser007(397),
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trTea stih ekli a aVIoPm e(Wtayr ieha,darr rrcdayhaohli = ucdeerd lHC ni the n,umle pm;a& akaohpie)mly

sith llwi aeld to ecoalmbti iadscsoi td/ sols fo irbbca ni sotol

btl_nyc  Chloride is increased though. +  
maxillarythirdmolar  This comment is gold. @btl_nyc, this is actually accute. you would expect hyperchloremia https://www.ncbi.nlm.nih.gov/books/NBK507698/ +  


submitted by usmleuser007(397),
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PPI -s:cfestefeid + denrcasie kisr for C. fdfi + aedcsneIr ikrs rof rpes csoetniifn + nca aecus ahigpyanosme + redescae nospabtior fo (a2,+C ,gM+2 p&;ma inor) + rineasedc skri of oootcetirosp ihp rutsfrace dt(/ owl sremu iau)cclm

imnotarobotbut  That's not the right answer tho, the answer is the binding of PGE to it's receptor +  
tinydoc  Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1  
maxillarythirdmolar  Keep it simple, stupid. +1  
roaaaj  @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +  


submitted by sympathetikey(1368),
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I see htwa reyh'te sgyani shti( was my dcnseo ce)iohc but ta the asem tmei I efle eikl a pacukb fo loodb dlwou aacvtiet het eroorcrbespta dan secau ardsedece eamhtyscitp iatyvcti ot eth SA am&p; VA odne.

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  


submitted by gh889(128),
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nspmcsoeoir of hte monomc eopaernl nvere as it wprsa arnudo hte enck of eth ufaibl cesaus daersdcee aesniostn mfor the curpesiialf oeaprlne r,nvee spebsrionle fro het lerlnroaaetta patcse dan dumors of eht gel adn tofo

eDep eaorepln vreen is snsoyre ot eth swpecbea ewtbnee het huaxll nda n2d tigid

cpi

maxillarythirdmolar  You might be able to damage the superficial peroneal nerve with damage to the lateral malleolus but the description in the stem has deficits in the end targets of both the deep and superficial peroneal nerves +1  


submitted by mousie(220),
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uroY atitrpyiu torclaotp lscle yoepryrhpht dgrniu crennypag ot eprdcou csngeainri umantos of lnrapctoi - trap of the paighspytoolhoy fo h'eehSasn .mn.y.resdo rsedencai blood sslo rndugi erdvliye acn eusac sihmicec srsocnie fo uytaitrpi

tinydoc  I thought the elevated Estrogen and progesterone depress the function of Prolactin until delivery. I guess you needed to know that it decreases its function by downregulating receptors or something as opposed actually decreasing the prolactin production. I picked gonadotrophs. This was a fair question but I reasoned it out and arrived at the wrong conclusion. +7  
maxillarythirdmolar  Specifically, the estrogen is stimulating lactotrophs as progesterone is preventing the prolactin from actually working on the breasts. So it's the estrogen that is stimulating the lactotrophs to grow, and you would see the effects of this growth if it weren't for the progesterone preventing the action of prolactin (their secretory product) on the breasts. +9  
dul071  why not somatotrophs. she's understress. wouldn't that increase the production of GH +  


submitted by cbrodo(61),
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The ertrsoopi cmsloun (uuclcisaFs scitaueccsFusa/lunu lcrgsia)i acryr toiamnonfir ot teh nabir aiegrgndr prt,epiiopcnroo torinia,vb crimstidnaiive cutoh dna ue.epssrr chisaylP exam sidfning gstsgue a islnoe hree eh(t pmtaaihonislc tarct eiacrrs ppkiac/innpir adn ,pereettmuar nda etshe erwe m)oa.nrl cSnei het npiteat sha lomrbana igdnisnf in eth orlew t,mxtieseeri nad lomarn ngdiifsn in teh pepru iextirs,teme teh snearw si clucFauiss rc.sliiag hisT is ueacebs roaitofnnmi ormf bdoy aeras loewb het lveel fo 6T si recadri by rgailsic nad rtonoanmfii mfor odby saear beaov eht llvee of 6T si edcirar by ausetncu.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +4  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30  cat5280...so spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  


submitted by beeip(124),
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Tish ahs enbe a uhgot onptcec orf me to tge, tbu I kihtn 'mI ylnlifa erh:te

eTh mtes is irebdsnigc mpriayr dralane fciicny,esnuif ro iAs.od'nsd

  • TCHA is ingbe cd-ovprreudoe ot tietlmuas teh srdaenal to doupecr scl,toroi utb ehyt nta'c dsr,open iterhe deu to ryohpta or tdotnersciu BT,( ntmoemaiuu: R4D, c.et)
  • ehT sfrti 31 minao casid fo CHAT nac be ldvacee ot rmfo α-MS,H hihcw laseumtits ytmns,elocea casniug gapiyhnrotpiemnte
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  


submitted by whoissaad(84),
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ehrWe is hsti vnee m?rof My dsinm' ginog yha weir itgyrn ot dnadtesrnu .htsi

sahusema  Hardy Wineberg equilibrium square root 900 = 30 1/2 of all offspring will be carriers so 30*.5 = 15 simple as that +6  
maxillarythirdmolar  this deserves a million upvotes. +1  


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sTih is wtah I ohtthgu btu not ruse fi ist’ ercor.ct Trhee is a WldUor q wereh ti irdesesbc riato-csmiidtaonn fo osictrlo dna eip.inephern iloCrsot tyianiglfnsci eshencan the etcfef of pei uacseeb tioorlsc sah a sersmvepii fectfe no annimiiatgn teh eraceingrd terpcsoer.

194orbust  per UWorld, "cortisol exerts a permissive effect on many hormones to help improve the response to a variety of stressors. For example, cortisol increases vascular and bronchial smooth muscle reactivity to catecholamines". FA also uses the effect of cortisol on catecholamine responsiveness as the lone example for a permissive drug interaction (FA2018 pg 229). The difference here is that we're talking about exogenous glucocorticoid and adrenergic agonist. I guess it was expected for us to assume that the mechanism is analogous for the analogous drugs +13  
maxillarythirdmolar  I'm sure it's related to the activating effect of Cortisol on phenylethanolamine-N-methyltransferase, converting NE to Epi. Sounds like a synergistic thing to me. (FA.83) +3  
feeeeeever  My logic is probably flawed, but I also thought that if cortisol has the ability inhibit COX, LOX, and NFKB you can reduce inflammation and bronchoconstrictive mediators. Therefore, the B2 agonists would have a greater effect since things like LTB4 will be reduced. +1  
feeeeeever  *LTC4, LTD4, LTE4 for bronchoconstriction, my bad +1  


submitted by lnsetick(93),
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  • nPoiecrA = ruoy pimsart lmsle keli na EAP
  • eeRUnMc = ’strhee on OORM in uoyr aers cseni rehy’te fllu fo xwa
  • CnCYeRE- = wehn ouy ,CEecsrie oruy repos are YgnRiC
  • uoEcaSBes = ESmBu si nEEPSig otu of royu oserp
hungrybox  as an ape i'm offended +31  
dr.xx  stop being an ape. evolutionize! +7  
dbg  as a creationist i'm offended +11  
maxillarythirdmolar  Also, Tarsal/Meibomian glands are found along the rims of the eyelid and produce meibum +  
snripper  So why is it apocrine? The dude is EXERCISING when playing football. +2  
qball  The question asks about "the characteristic odor" i.e. body odor coming from the APEocrine glands. The Eccrine glands secrete water and electrolytes. +1  


submitted by haliburton(214),
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iP-er ro rttsomappu tyyodprchiaamo (PPMC) si a er,ar eenn-trfglitheia hrtea adsseie of nerlcau oiirgn dna is ccreadheatirz yb atreh liuefar fo dudens senot eenewbt eth lfian kwees of enngcapyr nda 6 honstm efatr d.ieyverl knil ot mbuedphTe ialcilcn pcietur of CPPM nproesscodr to a idaeltd rhpdotoiycaaym M)(DC htwi ssgni fo sevree terha fil.uaer

maxillarythirdmolar  For anyone wanting to understand why^ the tl;dr is that prolactin gets cleaved into two toxic metabolites. Treatment is something like bromocriptine (and therefore no more breast feeding) to stop prolactin release. Lastly, you can treat with regular HF meds. +1  


submitted by cantaloupe5(77),
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Hdirriyytyomeop/hphs si gnsdiadoe hitw HTS w/ rflxee to T4 h(its utjs ltlse the abl fi SHT is olamnr todn’ chkec T4 tub if TSH si amn,lbrao heckc T4 .t)oo HST a’twsn na ptooni os 4T si het sebt .eawrns

hello  I don't get why this was downvoted... +2  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +  


submitted by assoplasty(94),
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I hnikt the cocpetn the’ery egsntit is het neacrsdie TGB ellsev in aryegn,npc dna ont jstu ohrmpyeiitydshr ni ngelar.e

Wnhe senrenigc rof ymtoreshpidyoirh/py,h HST evsell ear AYLASW frlletepaierny ecdchek escaebu they aer erom ntssievei to uteinm sfredecienf ni 3./TT4 etOfn temis SHT lvlese can tdeamnoetrs a ecghna vnee nweh /4TT3 veslel aer in eth ncaulcliisb nrgae. Teh nyol ecopxeitn ot this wdoul eb in ycnrnegap d(na I suseg meyba lierv arlui?ef I otudb yeth odlwu ksa hsti .o)hhugt ghiH etngreso elesvl trvnpsee eth ivlre omrf bagkneir wdon TG,B indegal ot cdaiensre TGB llvese in the mure.s hTis dsnib ot free T4, ngadseiecr hte taounm of eablilaav eerf 4.T As a oecysmapront hmnsmce,ia STH veells rea ntleiastynr aidercsen dna eth RATE fo 4T drpiounotc is ecnedirsa ot lipnshree naliebse efer 4T eve.sll vewrHeo hte OATTL auomtn fo 4T si eres.dcnai

heT qinuotse is ginksa who to inormcf eyisrhorhmdiypt in a gtnpnrea amown -t;g&- uyo eedn to hckce EFRE T4 vlelse bes(aecu tyhe uhldos be laomnr edu to rptaomcsneyo .pesesorn) ouY acnotn hkcec STH llu(yaus eedvlaet ni npnycgaer to eatsopmnec for esnadirec GTB), dan oyu naoctn cechk aotlt 4T lesevl wlil( be e.caidne)sr Yuo otg eht nsewar ihtgr eheitr way tbu I nkith siht si a entrfeidf roisgnnea hwtor nsdocng,reii sbeecua tyeh nca kas htsi notcecp ni treho txetcson of eegt,ryoinmsrps-he dan if yhte tislde “”STH as an nrwaes hcceio htta udwol eb ot.crnicer

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +8  
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +2  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +  
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +1  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +1  
lovebug  Amazing answer! THX +  
an_improved_me  Just to add: Pregnancy is not an exception to using TSH in suspected hyperthyroid pregnant patients (not sure in hypothyroid); you would still get a TSH first, and if its unusually low, you would then proceed to measure T4 (free, total), and so on. https://www.uptodate.com/contents/hyperthyroidism-during-pregnancy-clinical-manifestations-diagnosis-and-causes?search=hyperthyroidism%20in%20pregnancy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H994499 +  


submitted by temmy(130),
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lepesa elph cgrdianco ot strniew ieatnuqo teh tanetpi ahs a lrnmao oiann gap

ergogenic22  winter's formula is to look at the compensation to see if it is appropriate. PCO2 = 1.5[HCO3-] + 8 +/- 2 In this case, 1.5* 10 (Pt's bicarb) +8 +/-2 = 21 to 25 Pt's PO2 is 23, so compensation is appropriate. If PCO2 was below 21, it would be concomitant respiratory alkalosis +5  
ergogenic22  in other words, winter's formula is not necessary for this question +2  
the_sacramento_kings  lol unless you want to make sure its not A. +1  
hello  @ergogenic22 Someone might use Winter's formula to rule out choice A. +  
maxillarythirdmolar  respiratory depression of alcohol should rule out "A" +  
baja_blast  Isn't the low pCO2 enough to rule out A? +1  


submitted by hayayah(1079),
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ifeDtiionn of jtmtendasu rdrodeis:

otEnaomli sosmmtyp (eg, nexiayt, se)ondsirpe hatt rccuo iitwnh 3 nsmhot of na nfdiabltieie aclpcyoihsso rrtossse g(e, vciord,e l)lisnes gitasnl l;&t 6 onmsth onec eht setosrsr sah ne.ded

fI msypmtos estpirs gt;& 6 nomhts ftear erssrtso sd,ne it si .DGA

hello  Yep, and I think what we are supposed to take from this Q is: The only info. we have for this patient is that he ended chemo 2 months ago and has been calling the doctor a lot -- this is supposed to mean he has been calling a lot since ending chemo 2 months ago. His frequent calls starting after ending chemo and within 3 months of the stressor fits with the above-stated definition of "adjustment disorder" with anxiety. I stressor in this case could possibly be either the actual illness or the ending of chemo/treatment. It probably does not matter much in this case. +4  
charcot_bouchard  I think doing uw done me wrong here. Adjustment disorder isnt diagnosed when symptom match another disorder --- it was like never a right answer. But ofc its right answer in nbme +5  
maxillarythirdmolar  Just to add to that, the tingling in his fingers may seem like a distraction/it probably is. Likely has some relation to his Chemo. +3  
j44n  shit I thought this poor guy had OCD with all the repetitive behaviors. +1  


submitted by neonem(571),
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evOisrbtutc hyotpuar seusac a olrtnespa zeatamio tg;-&- hwen leg,odonrp ulbuart magdea neusse. Tshi dsale ot na cetua bturula nrosiesc, trcdcarzeaehi by crcneiot uglps ni the uuarltb ystesm as esen in hte aegim

meningitis  Does anyone know the relevance of the stem saying: "during this time she also has been crying frequently"? +44  
usmleuser007  Think the postrenal azotemia is d/t her pregnancy. With the increasing in size fetus, the pelvic cavity is being compressed and thus there is pressure on the ureters. This leading to the presentation. As per above --- the crying maybe just d/t her pain and emotional stress caused by worrying about possible complications regarding her fetus. +4  
maxillarythirdmolar  My gut tells me it must be some sort of transient change in placental size with hormonal changes. It's reminiscent of what you might expect for breast changes during the menstrual cycle, imo +  
j44n  or maybe the fetus is literally crushing her ureters into the wall of her pelvis and shes got an infected kidney +2