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Comments ...

 +1  (nbme22#49)

I wasn't sure, but then I realize he is going to die, he is in a hospice + the best you can do is made him feel without pain. BUT at the end what made me decide was The reason of the medication. At this point you really don't care about controlling everything else.

Subcomments ...

submitted by yotsubato(1030),
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Wyh anct tshi be vaxisteal? hoBt lowud sueac cteamilbo lsolskaai wthi a.k.ymoali.hep ?

sup  Laxatives would cause an anion gap metabolic acidosis due to loss of bicarbonate in the stool. You would see hypokalemia though as seen in this question. +1  
miriamp3  it took me a lot of time choosing between laxatives and diuretics and at the end I choose diuretics. but I didn't realize that the only thing I had to do was check if were a anion gap or not. +  
snripper  Why would laxatives cause anion gap MA? Isn't it similar to diarrhea? +  
castlblack  The above comments are incorrect. Diarrhea is a cause of normal-anion-gap metabolic acidosis (D in HARDASS from FA). Laxatives are wrong because they would lower HCO3- but in this scenario it is high. The low K+ and Cl- fits either case though. +4  

submitted by mattnatomy(43),
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eAwnsr = C. (asDdeecre tcpeahi DLVL nthesysis)

iccioitNn daic = icnaiN. icNnia wkosr :by

  1. nigbhIinit islslopyi rmonh(oe ieneitsvs )psieal ni asoeipd )iseust

  2. degRcuni ciapteh VLDL tsiyshsen

johnthurtjr  Well color me surprised. I was completely thrown off here. +33  
miriamp3  @almondbreeze go to the cardiovascular pharmacology you will see a draw of lipid lowering agents and you will find niacin en two places ++one on the adipose tissue and the second one in the liver by the vldl production. in the text in the same page is also mention it FA 2018 pg 313. +  
djeffs1  I still don't quite see how C corresponds to those 2 processes... +  

submitted by usmleuser007(396),
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suJt teon hyw thoer rsswnea rea ton ccrrot:e

  1. &o;gsyohEnsbipnp na esercdina nesoenrca of ceoiv ssdoun haedr enwh nuiutgcsltaa eht ugn,sl nefot saedcu by nlgu odconnolsaiit dan sorbsii.f

    • .a It si eud to dcnnheea osritsnasnmi fo ihechrnfy-gequ sdoun osarcs fdu,li cshu as ni blmaoanr nlgu ise,sut htwi welro uerenecisqf letrfdei
  2. eWisedprh rncsfbp&oeusrpryeqeto;il ot an esenriacd sslndeou be&rngidsnst;si;pbhnpof&nowpe irngdu snutlioaucta hwit a tsepteochos on het ulng elfdsi no a sne’aitpt oorts.

    • a. llaysuU ksnepo osusdn of swnl&enmdhspaovrpupsi;&bb;ee by eht tnaeitp odulw ont be rdhae by eht iiiannlcc alcntisuagut a glun fiedl whit a peocshtt.eso

    • b. r,eeHovw ni seara of teh guln eherw hrtee p&snbg;ulsni niatdo,oslconi heets hedrwsipe psoekn susdno by eth tenaipt uhc(s as insgay e-nint)n’eny‘i illw eb lcreayl erdha uhgrhto eht ecthes.toosp

    • .c ihTs cneeirsa in unods siesxt beucesa ndsou avltesr tresfa nda sthu iwht eworl loss of etnystnii trhugoh qludii or diols d(“lfui ss”ma ro “iolds ,”smsa yctlisrp,eeev in the )ngul vsuser gsueaso iar( in the ngl)u adem.i

    • d. rsidehpWe yuqcoprltoie si a nilliacc etts liyctlpay rrdeoefmp ugndir a admeicl hpyclsia toainnixmea ot velaueat ofr teh cpsenere ngon&;sfbplu ndnoosaoct,iil ichhw ucodl be sudace by nrceca dsli(o ass)m or paounnemi l(iduf

titanesxvi  why not wheezing? +  
miriamp3  @titanesxvi because the dx is CHF +  
leaf_house  I get why crackles are more likely in CHF, but wouldn't it also cause whispered pectoriloquy, if fluid allows better transmission of sound? +  

submitted by bubbles(69),
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Chcorni realn :iunfcnisfciey

1) ropo pshtaheop elenraacc --;t&g ighh emsur gacironni rhhusooppos

)2 hhgi umesr eohtappsh t-g-;& mpeleoscx wtih lietnavd cnoati aC ;gt--& Ca sfall

3) aC sflal tg-;-& setrrgig HTP isax

)4 ekndiy efulria &-tg-; reedescad itvitcya of dlyros-yh1axe at teh nkyeid &t;-g- sles riaccloilt

makinallkindzofgainz  this guy renals +6  
paperbackwriter  Someone please help me with this (always trips me up): PTH causes increased vit D production in kidney... are we assuming the increased PTH can't catch up with the kidney failure? Is it the level prior to PTH compensation that they want? D: +  
miriamp3  @paperbackwriter what it works for me ;;;; is find the first abnormality so CKD low calcitriol (no D vit) ---> is gonna increase PTH ---> the kidney are not working (chronic, they don't tell u recently- you can;t revert a CKD so the kidney never going to catch up) --> increase inorganic phosphorus.--> always start with the problem. I also use this for celiac and types of shocks. start with the problem, and trust yourself. +2  
paperbackwriter  @miriamp3 thank you! I will try out your strategy next time!! :) +1  
snripper  I thought renal insufficiency -> inability to reabsorb phosphate at PCT -> decreased phosphate? +2  

submitted by haozhier(18),

I chose C because I thought it has been four weeks so it must have been acute tubular necrosis. Can anyone explain? Thanks!

miriamp3  @haozhier if you are deciding to think that he had a ATN because of the 4 weeks.. then he should be by now in the recovery phase(polyuria, Bun/cr fall) But he is with HF and his urine output has progressively decrease. So AKI prerenal HF Bun/cr >20. the only one is D. Don't get confused with the rest of the information. +  
jesusisking  I thought the same thing so chose C as well! +  

submitted by seagull(1554),
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thaW a relretbi ucrpte.i Tyeh yeth decervo pu prat of ti ithw TWF

sympathetikey  Agreed. +14  
catch-22  Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX. +3  
yotsubato  I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8 +11  
lolmedlol  why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
catch-22  ^Also, you know it's the ventral aspect because you can see the medullary pyramids. +1  
amarousis  think of the belly of the pons as a pregnant lady. so you're looking at the front of her +4  
hello  which letter is CN IX in this diagram? +  
miriamp3  there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
ljennetten  G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons. +1  
prolific_pygophilic  Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture +1  
soccerfan23  There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q. +