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Contributor score: 112


Comments ...

 +0  (step2ck_form7#44)

I got this wrong, thinking it was myositis ossificans due to the history (six days ago he was evaluated for twisted knee at a game with improvement of sxs until one day ago).. guess i should have payed more attention to his PMH


 +4  (nbme21#46)
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lTol klei pertsroce rea nptrtea oigncnioter rserpteco no( neiant imnmytiu lelcs klie h)gaesoaprmc ttha gerozeinc pteognha esasiatdoc uomecalrl steaprnt A(M)sPP nad leda to cotavatini of -NFB.k enO paxleme of a APMP is LPS a(gmr tvaieeng beia.rtca) sTih saedl ot nticeoser of -,L1I L-I6 cea(su efe,)rv NFaT- ss(cuae eevfr nad nsoipe)y,onth irNcti iOdex s(ceasu nhse.ponioy)t

pemmonetCl ttcinavaio sfelit aslde ot opostyihenn iva 3a,C sa ew.ll

llA itsh cna be fuodn no gaep 313 no ,FA sa instnm@igie nidpteo t,ou nda egap 99 fo AF 29.01


 +2  (nbme21#37)
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In ibeticda eosoicsad,kit rhtee is daeneirsc acdi ni het uaexellcratrl as.pce odicAcrng ot AF etreh is a lrtrslnlaauce ifsht ude ot sededacre iuinnls htta lsdea ot rmeo H+ nnteirge het elcl in eganexch ofr +.K Tish ldesa ot aaplerekimhy htwi tlededep rcreiltlnuala soetrs fo +K. eehrT si olas tomcois duriiess that dlesa to eenracsdi +K olss ni hte rnieu dan talot odyb +K tn.olpdeei The isentuoq kass hatt si osmt llkiye ot sradeece whti lnuisin hyrpaet: mures isamsutpo nctnontroeica wlil aeceerds as +K is wno hxgdnaece fro H+ seniid hte ce.ll

cienfuegos  Additional UW fun facts regarding Potassium and DKA: use caution giving insulin and IV fluids to dehydrated hyperglycemic because i forces K in cells causing fast decrease of extracellular Potassium, thus give K supplementation even when serum K elevated +3
linwanrun1357  Why urine K+ does not decrease? +3

 +5  (nbme21#43)
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M. eiursubstocl ecirlesatp in na ndceechku fsnaohi itniwh teh alvloie nad arvlolae camoearpghs eud to veienurcl satcorf dcro( )caoftr atth ervnetp am-hatgcmdearpoedie loyasemgoohsp dscutoitenr. erAtf a wef kewes, cagrmhpoesa nfdtceei spilyad ngneati on MCH II to auimlstet T D+4C elslc chihw dalse ot na cenisare in yornfrtneie- (1Th nc)tyekio ahtt aeitvc apmsrcaehgo. aediAtvtc garmocpsahe cna laos etnitefdeiafr toin poihedteiil iytheicosst nda alcceseo iont eemtlaliucnutd sahngnaL ignta ecsll tath wlal fof treruaclaelxl oaetrmicyabc niihtw agmnlarus.o


 +12  (nbme20#11)
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heT ytsoighol si fo heoysptserc lal(sm slrcahiep eclls w/o anctrle .ra)ollp eedyiHrart osspcthysireo is due to ftecde ni inroetsp nnriittagec thwi CBR rmeemban eetlnosk dna lasmpa mnreeabm yan,nrik( nbda ,3 tonreip ,24. crt.)nsiep Mtsoly ooasutlma niatnmod tnhnereciai (so rgueezohoyts uimntato sniec you ynol dene one tamunt lleeal ot egt the aieess.d)

wuagbe  To add to this: homozygous HS presents with hemolysis even in absence of stressors. this patient is only presenting with pale skin, and there are no schistocytes on the peripheral smear, so it's a heterozygous ankyrin mutation. +8
pg32  I wanted to pick hereditary spherocytosis but the mean corpuscular concentration was normal and I thought it was supposed to be elevated? Also, why are there so many RBCs that are way bigger than the spherocytes? +6
nephroguy  I'm assuming that the MCC is normal because the patient is heterozygous for HS. Not sure if this is correct, but that was my thought process +1
draykid  Are there any papers that explain the difference in expression of homozygous vs heterozygous HS? +20
waterloo  I don't know if that matters as much, like the phenotype difference of homozygous or heterozygous for this question. Since you only need one allele to show this, play odds. Is he more likely to have AA or Aa. That was my thought process. Also if you see spherocytes you'd be going for ankyrin right, not B-globin bc that should be target cells - regardless of MCHC. +1
alimd  as I remember AD are always heterzygous. Because homozygous are always lethal. +4




Subcomments ...

submitted by seagull(1573),

Imagine a world where the author put things like kidney stones, constipation, altered mental status or GERD. But, no. We get the first level of hell where all these authors take fat Shits on the students. "Thank you sir - may I have another?"

nala_ula  your comments to BS questions <3 +  


submitted by seagull(1573),

SO Pulmonary Angiography has dye that shouldn't be used in CKD.

Why does the question need to be like a book in length. I was balancing like 20 ideas with her F**King diabetes and HTN. WTF

nala_ula  literally +  


submitted by step_prep5(74),
  • Key idea: While physicians should be on the look-out for signs of opioid addiction in patients receiving pain medications, in patients with metastatic cancer to bone it is common for them to develop tolerance and for the pain to progress, so their requests for increased pain management are valid and should be managed through a palliative care lens
  • Mild cancer pain: Acetaminophen, NSAIDs
  • Moderate cancer pain: Weak opioids (codeine, hydrocodone, tramadol)
  • Severe cancer pain: Strong short-acting opioids (morphine, hydromorphone) –> Long-acting opioids (fentanyl, oxycodone) and short-acting opioids for breakthrough pain

https://step-prep.org/tutoring/

nala_ula  also, since she has metastatic cancer and is cared for in a home, we're assuming she's at end of life care, therefore managing pain is more important than any side effects the opioids could have +  
lindasmith462  it just says "at home" not "in a home" either way it doesn't tell us that she's a hospice pt and she should totally have an outpt workup for what are likely new bone mets (if she's still pursuing treatment). Also a HUGE part of palliative care/pain management is managing the side effects of opioids- some patients may handle the pain better than the constipation/nausea. +  


submitted by step_prep5(74),
  • Key idea: Systemic steroids are associated with psychosis and this patient is receiving ACTH, which will stimulate the adrenal gland to release increased amounts of glucocorticoids/steroids, likely precipitating her psychosis (delusions, bizarre behaviors, etc.)
  • Alprazolam = Benzo (avoided in older patients due to risk of delirium)
  • Amitriptyline = TCA antidepressant (refractory depression, neuropathic pain, migraines)
  • Lithium = Bipolar disorder
  • Sertraline = SSRI (depression, PTSD, panic disorder, etc.)

https://step-prep.org/tutoring/

nala_ula  so for NBME, 47 years is OLD?? This is vague, if they're going to make people choose between haloperidol and a benzodiazepine, shouldn't they actually make the ages in more of a spectrum? +1  
lindasmith462  not sure if this is steroid induced psychosis (other than some super old paper from the 50s could find anything related to ACTH and psychosis and it actually seems to be prefered over steroid tx in MS because of lack of psychosis sx). Also benzos could be used first line for agitation/delirium/psychosis but I think its only lorazepam or midazolam? IDK I hate the NBME so much rn on this Q +  


submitted by step_prep5(74),
  • Unilateral vision loss + Dilated retinal veins and widespread retinal hemorrhages on fundoscopy (“blood and thunder” appearance) = Central retinal vein occlusion
  • Central retinal artery occlusion = Cherry-red spot on fundoscopy
  • Corneal abrasion = Positive Fluorescein staining, sensitivity to light, pain
  • Glaucoma = Bilateral lens opacity and glare from lights
  • HSV conjunctivitis = Dendritic ulcers
  • Optic neuritis = Optic disk pallor

https://step-prep.org/tutoring/

nala_ula  Thanks for this! but i think you meant to write cataract instead of glaucoma +  


submitted by colonelred_(106),
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The diiasgsno si wasrteyrrb noamiahegm, lycomonm pnspeah in ksi,d tfeno rlvsosee on sti won sa hyet get .rdleo

shaeking  A strawberry hemangioma is normally pink or red (which is why it is named strawberry). The description has a flat purplish lesion which makes me think of a port wine stain on the face. How do you know to think of strawberry hemangioma over port wine based on this question stem? +3  
seagull  the age is key here. Newborns have strawberry hemangiomas typically on their face. Sturge-Weber could also be the case but none of the answer choices matched to that description. +1  
vshummy  I would agree with Sturg Webber nevus flammeus but I also noticed First Aid says it's a non-neoplastic birth mark so I should have known not to pick malignant degeneration or local invasion. Also because capillary hemangiomas don't have to be flat but the nevus flammeus is consistently flat. But I'm also reading on Wiki that the nevus flammeus doesn't regress so they must be trying to describe strawberry hemangioma even though I don't agree with their color choice... +  
nala_ula  Maybe (and I can only hope I'm right and the test makers are not -that much of- sadists) they would have made sure to write "in a cranial nerve 5 (either ophthalmic or maxillary) distribution" if it were Sturge-Weber. +1  
j44n  this is literally on every NBME along with the 10,000 ways to not get a boner +1  


submitted by haliburton(214),
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2FE si alalaositnnrt eigootaln racfto 2, wchih is acrsnysee rof ieopnrt y.nsisthes

sympathetikey  I. Am. So. DUMB. +25  
nala_ula  same :( +2  
lovebug  At first, E2F flashed through my mind. then I thought maybe EF2 is elongation factor for transcription. DUMB. :( +  


submitted by nosancuck(87),
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oY gadw ew lal abotu PTV TIM LLaH

lnaylPeehnna,i Veina,l ArKpoT,yNDt T,erneihno ucnei,leIos itoenM,einh sHineiid,t uineeLc eisnLy

meningitis  I don't understand what the question is asking... can someone please explain it to me? Patient doesnt eat protein, shes chubby. What does methionine have to do with this? +2  
charcot_bouchard  Just basically asking which is essential amino acids. +3  
usmleuser007  Essential amino acids (something i came up with) 1. "Three HAL fans will try meth" a. Threonine = Three b. Histidine; Arginine; Lysine = HAL c. Phenylalanine = fans d. Valine; Isoleucine; Leucine = will e. Tryptophan = try f. Methionine = meth +3  
nala_ula  They're saying there is a lack of good quality protein -> slight nutritional deficiency. She may have acquired weight but it's not because of protein. So they're specifically asking what amino acid she might be missing due to her subpar diet. Since essential amino acids are those that the body cannot make itself, out off those listed, methionine is the essential amino acid. It's on page 81 of FA 2019. +11  
nala_ula  correct me if I'm wrong please :) +  
hello  For anyone confused trying to follow @usmleuser007's comment -- slightly modified Essential amino acids mnemonic "Ah, Three fans will try meth" Ah = arginine, histidine Three = Threonine Fans (phans)= Phenylalanine Vil (Will -- German accent pronouncing English word 'will') = valine, isoleucine, leucine, lysine Try = tryptophan Meth = Methionine +1  
pg32  Why does @hello and @usmleuser007 mnemonic contain arginine? That isn't in the PVT TIM HaLL mnemonic for essential amino acids... +  
paperbackwriter  @pg32 arginine is semi-essential. It is essential in preterm infants who cannot synthesize it https://www.sciencedirect.com/science/article/pii/S0955286304000701?via%3Dihub +  


submitted by nosancuck(87),
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Yo awgd we lla aubto TVP MTI HLaL

nay,elnnePiahl ale,iVn prtDAo,NKyT Trneioh,en sleiuc,enIo eitnoi,Mhen i,iidHsnte eeLcinu snyeLi

meningitis  I don't understand what the question is asking... can someone please explain it to me? Patient doesnt eat protein, shes chubby. What does methionine have to do with this? +2  
charcot_bouchard  Just basically asking which is essential amino acids. +3  
usmleuser007  Essential amino acids (something i came up with) 1. "Three HAL fans will try meth" a. Threonine = Three b. Histidine; Arginine; Lysine = HAL c. Phenylalanine = fans d. Valine; Isoleucine; Leucine = will e. Tryptophan = try f. Methionine = meth +3  
nala_ula  They're saying there is a lack of good quality protein -> slight nutritional deficiency. She may have acquired weight but it's not because of protein. So they're specifically asking what amino acid she might be missing due to her subpar diet. Since essential amino acids are those that the body cannot make itself, out off those listed, methionine is the essential amino acid. It's on page 81 of FA 2019. +11  
nala_ula  correct me if I'm wrong please :) +  
hello  For anyone confused trying to follow @usmleuser007's comment -- slightly modified Essential amino acids mnemonic "Ah, Three fans will try meth" Ah = arginine, histidine Three = Threonine Fans (phans)= Phenylalanine Vil (Will -- German accent pronouncing English word 'will') = valine, isoleucine, leucine, lysine Try = tryptophan Meth = Methionine +1  
pg32  Why does @hello and @usmleuser007 mnemonic contain arginine? That isn't in the PVT TIM HaLL mnemonic for essential amino acids... +  
paperbackwriter  @pg32 arginine is semi-essential. It is essential in preterm infants who cannot synthesize it https://www.sciencedirect.com/science/article/pii/S0955286304000701?via%3Dihub +  


submitted by halux(12),
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nca meso eon ealeps enlixap ywh is hte alsia?ehpryp

beeip  Loss of negative feedback from resected ovaries leads to gonadotroph hyperplasia. +2  
halux  so, the explanation is that in the absence of Estrogen negative feedback inhibition to LH and FSH, this leads to Gonadotrophs Hyperplasia at the Pituitary resulting in elevated LH and FSH secretion levels? I get busted by this one :/ Thanks in advance! +12  
nala_ula  @halux exactly, there's no negative feedback telling them there is an increase in the hormones (since there are no ovaries) so gonadotrophs work in overdrive to keep stimulating the gonads via FSH and LH. +1  


submitted by asdfghjkl(3),
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Ayneno nowk ywh -IF1G wlnd'otu be eercandsi as ell?w RHHG si esltudamti in cpgeyioymlhc sat.ste

nala_ula  Honestly, it's something that has confused me for a while. Why is it that GH secretion is stimulated by hypoglycemia? I mean, it's literally called growth hormone (for growth!), and hypoglycemia, which is basically a "starvation" state, will stimulate this hormone? +  
shaeking  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529368/ This might help answer your question. I basically didn't pick IGF-1 because it would increase the uptake of glucose leading to a worsen hypoglycemic state. Didn't have a true reason otherwise. +  
temmy  IGF-1 is regulated by insulin. so it will be decreased because insulin levels are also low. +2  
nala_ula  thank you @shaeking! +  
nwinkelmann  I found this and it also explains to a more genetic/cellular level. Essentially, it says that starvation induces some factors that cause GH resistance and IGF1 suppression. +1  
nwinkelmann  Sorry forgot the link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575072/ +  


submitted by tissue creep(113),
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phtdroAro rof u,ser tbu ofr het rrodec 'Im ptreyt seur hist saw nikgauuyhnC .usVri Only tgo thsi rfmo a WodrlU sqinutoe as I nat'dh eesn it ntliu ,enht ubt pnpaetylar eht hraiargalt si alrely adb, hcwih is thwa erdw em ot eth nw.ears

psx.:hemhd.w/i/nnkwldtcugct/t.gi/hwnauvyco

meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +12  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +2  
namira  dont be shocked! me too! exito! +2  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +21  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +2  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  
lovebug  FA2019, page 167 RNA virusesy. +  
lovebug  Found that Chikungunya also have Rash./// An erythematous macular or maculopapular rash usually appears in the first 2–3 days of the illness and subsides within 7–10 days. It can be patchy or diffuse on the face, trunk and limbs. It is typically asymptomatic but may be pruritic (Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007; 45: e1. ) +1  
beto  it is chikungunya->fever, polyarthralgia, diffuse macular rash, dengue has retro-orbital pain mostly +1  


submitted by hajj(0),
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nca yonean elpxian sth?i i owkn dmaien orf y is ehghri by iancaltcoul utb x sah two oemds os woh eomc y ash hheigr eodm?

lispectedwumbologist  The mode in X is 32 and the mode in Y is 80 +  
lispectedwumbologist  The mode in X is 70 and the mode in Y is 80* +1  
hajj  Thank you! +  
hungrybox  Just checking in so I could feel smart about getting this right despite bombing the rest of the test lmao +4  
usmleuser007  can someone please explain the median in this +  
nala_ula  The median can be known by first assembling the numbers in order from least to greater. If it's an uneven number set, the number in the middle is the median (for example: 4, 10, 12, 20, 27 = median is 12 since this is the number in the middle); if the numbers are even then you have to take the two values in the middle, add them up and divide them by 2 [for example: 4, 10, 12, 12, 20, 27 = (12+12)/2 = 12]. Page 261 on FA 2019 explains it as well. Not sure if I explained it well... good luck on the test, people! +  
dubin johnson  Can someone please explain how the mode for Y than X. Not sure how we got the values above. Thanks! +  
dubin johnson  I mean how is the mode for Y greater than mode for x? +1  
sgarzon15  Mode is the one that repeats the most once you list them in order +  
usmile1  Median would be the BP value that the person in the 50th percentile of each group would have. So for group X, to find the 50th percent value, I added 8 + 12 + 32 = 52, which is right above 50, so the median would be 70 mmHg for group X. Doing the same thing for group Y, 2+8+10+20+ 18 = 58; the 50th percentile would fall in group that had a BP of 90 mmHg. which makes the median higher for group Y. hope that isn't wrong, and helps someone! +4  
poisonivy  I did it the same way! not pretty sure if it is the right way to do it, but it gave me the right answer! +  


submitted by aishu007(3),
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nca oynean palenxi yhw reucnioasoaflecesctc si the enrwas ehr?e

priapism  Best I can guess is that both S. aureus and E. faecalis can cause UTI, but S. aureus is described as having clusters where as the other Gm+ cocci are in chains +6  
nala_ula  My doubt here in this question is the fact that Enterococcus faecalis is a normal gut microorganism that causes these different symptoms of sickness after genitoruinary or gastrointestinal procedures... but in this question there is no mention of any procedures. +  
fez_karim  its says chains, so not staph. only other is entero +  
temmy  according to first aid, staph aureus is not one of the high yield bugs for UTIs +1  
temmy  uti bugs are E.Coli Staph saprophyticus Klebsiella pneumonia Serratia Marcescens Enterococcus Proteus mirabilis Pseudomonad aeruginosa +  
privatejoker  Where in FA 2019 does it list that C.coccus is specifically in chains? +  
privatejoker  E.Coccus* i mean +  
divya  @privatejoker FA 2018 Pg 134 table +  
jennybones  @privatejoker Enterococcus is Group-D STREP. Streps are arranged in chains. +2  
santal  FA 2019 Page 639, too. +  
backwardsprogress  Enteroccocus is also a pretty common cause of chronic prostatitis, which was the give away in the prompt if you didnt know the characteristics of entero: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715713/ +  


submitted by hyoscyamine(55),
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hTis si ltalera gnrleybaleuA/mar/dlWePICl oedsnymr. Teh wmaon hsa agedma in teh yaimsthecpt anchi (yonerss seodrysnm are etraall gocarindc ot het eulr fo s4) srguietln in Hernro dyonrm,es inhcmalasoipt tctar mnipept(/a chhwi ear aosl y)r,snoes dan CN XI and CN X nynotfduisc relitgsnu in het dygrahtshyai/spiaard eps(hl su ielzocla ot eht ).amdlule

nala_ula  Also, just to add, FA specifies that Nucleus ambiguus effects (dysphagia, hoarseness, decreased gag reflex) are specific to PICA lesions. +2  
cienfuegos  Thanks for the input. I have always found this topic to be tricky and just came across this article that helped me out a ton regarding the rule of 4's hoscyamine mentions above. https://rdcu.be/bLjOB +7  
lovebug  FA 2019 502pg! +  
pfebo  "Don't PICA horse (hoarseness) that can't eat (dysphagia)" +1  


submitted by hayayah(1079),
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rcdeanoSy proeirdhpsrmhytyaia usu(ylla dt/ hrcicno enarl l.uefia)r

bLa gnfidsin lnuiced ↑ THP s(snerpeo to low ila,mu)cc ↓ semru ccluiam rnea(l feulir)a, ↑ usrem ophtsaphe n(lrae fl,e)uiar adn ↑ anelakli apsoepthash P(TH ntciatigva seaoosBts.t)l

haliburton  also remember that in renal failure, 1-alpha-hydroxylase activity is down, so there will be less activation of 25-hydroxycholecalciferol to 1,25-hydroxycholecalciferol, which is a key mechanism causing hypocalcemia. +2  
cr  why not increased 25-hydroxycholecalciferol?, with the same logic haliburton explain +  
nala_ula  Increased phosphate, since the kidneys aren't working well, leads to the release of fibroblast growth factor 23 from bone, which decreases calcitriol production and decreased calcium absorption. The increase in phosphate and the decrease in calcium lead to secondary hyperparathyroidism. +1  
privatejoker  Probably a dumb question but how do we definitively know that the ALP is elevated if they give us no reference range in the lab values or Q stem? Everything stated above definitely makes sense from a physiological standpoint, I was just curious. +1  
fatboyslim  @cr the question asked "the patient's BONE PAIN is most likely caused by which of the following?" Increased levels of 25-hydroxycholecalciferol might exist in that patient, but it wouldn't cause bone pain. PTH causes bone pain because of bone resorption +1  
suckitnbme  @privatejoker ALP is included in the standard lab values +  
makinallkindzofgainz  @privatejoker ALP is listed under "Phosphatase (alkaline), serum" in the lab values +1  
pg32  Why does AlkPhos increase in renal osteodystrophy? The PTH would be trying to stimulate bone resorption (increase osteoCLAST activity), not bone formation (osteoBLAST activity). +  
drzed  @pg32 the only way to stimulate an osteoclast in this case (e.g. via PTH) is by stimulating osteoblasts first (thru RANKL/RANK interaction), thus ALP increases. +1  


submitted by yotsubato(1032),
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yhW is ish doibiL ?oramln I'ts yttaoll xetdcpee that eh amy ehva uedrdce ioibdl ferta hsi fewi died 2 ryeas ago fmor emso ehioblrr ogoedrlpn i.slensl

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by yotsubato(1032),
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Why is his bodiLi oramnl? s'It olytlat decetpex that he amy eavh ddecure dliobi artef ihs iefw died 2 erysa goa rfmo semo olierbhr pgnrelood llsisne.

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by yo(86),
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sThi rrccuoed hiiwnt 6 ushor nda dasuce mose auronylmp deeam dna operrrtsyia ritedsss eatrf a rtoasnnusif daesuc yb hte soor'dn euleac-tkoynti osnaeitbid stuj tdnoirsgey eth srecpntiie usoeihtrpnl and reoatirsryp lieonldaeht lsel.c

ihwle raiaylagcisaplxelnh/ can uasec tyioasrrrpe sterra dan kocsh ti sah a ewatsomh dtreneiff ,ieptruc on hze,enwig esnhsiict or rehvtawe nda coiracngd ot fitrs idA ti spneaph tniwih mueitns to 32- hosur cihwh is at laets dulebo awht re'ew insgee r.eeh also aerebw fo gIA nfctiiede pleope in ihts h.icoec

,PE eh I n'otd nkiht ti fcaestf 2Poa htta tfeno hcum dgcnocair to sith erpsu perdu ghih lieyd oeersr.cu tub uhh yaeh toen'sd efel EP ikadn euoqsn it/tre0a.m1lsenem0hotcc.dmac#s/0kdci-oepu9ti/e1p2w:rpce/i3

eipmnnoa, hritg reaft lla eth oifisnun ssbeisun nad on imnotne fo vefer ro at?hinyng a.Nh

og ot peag 141 fo srift .dai I'm rytpet sure we eend ot nkow uor iins/anorfulastnptn acpr eubcaes it tujs pseke monigc pu ni dlurow but ihst hewol xeam si a acpohr.ots

iFregov em if I daem a tg/simanwoekr btauo gh,ntanyi I mlotsy tgo fino rofm fsrti id.a lpz ocrertc fi heert is a eamk,tis oodg kc.lu

hungrybox  we gonna make it bro +7  
hungrybox  or sis +8  
nala_ula  I did the same, basically went through each one and the time of onset between each. Good luck on your tests!! +  
temmy  i don't think pulmonary embolism will cause bilateral lung infiltrate +6  
athenathefirst  I hope you guys made it. Your post 9 months ago +1  


submitted by meningitis(544),
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eWhn stidangn up, het ydob yllmoarn tisvcaeat spyhtticeam stesmy ot doaiv attrthiosco oih.ypsnoten

But icsne etrhe si onw na detidvai cftefe fo eth tpeohcoamycohrom gscean,idrre it wlli edal to a isenthopynre

ie.(: leuDbo sainocctoovstinr = Peho gaederncrsi + cpetiySahtm yt)sesm

sympathetikey  Brilliant. +5  
medschul  Would pheo have a normal resting BP though? +13  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +8  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by usmleuser007(397),
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stuj a uhh....nc lOrmeaoezp is lasywa eth tgrih esarnw

nala_ula  Famotidine is an H2 blocker which really only stops acid secretion via the stimulation of H+/K+ ATPase by histamine, but it still has vagus and gastrin stimulation. If you use Omeprazole, you get irreversible inhibition of the pump itself which stops the secretion of acid even if there is histamine, gastrin, vagus stimulation. +6  
temmy  what about the healing of her mucosa. Is that not the action of prostaglandin?. That threw me off cos according to FA, misoprostol increases secretion of the gastric mucosa +5  
cry2mucheveryday  same doubt..marked miso +2  
sahusema  I guess because misoprostol is more associated with treatment of NSAID related ulcers and PPIs are 1st line DOC for GERD? +1  
makinallkindzofgainz  @temmy, I think that Omeprazole is a better answer because although Misoprostol would promote healing of her esophageal mucosa, it wouldn't do anything to relieve the symptoms of GERD (due to acidic contents in the esophagus) +  


submitted by hungrybox(1044),
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nogwolliF a tekro,s shit ttneiap hda enwssaek of erh ftel ecfa nda yo,db so teh ktsero tusm vahe ceadfetf het gtihr side of hre raib.n B saw teh olyn chocei no teh rihgt dsei of erh .nabri

lStli nsfoc?ude dRae n.o..

The uyaotrlvn tromo irebsf lnrctpia(osoic ctrat) ncdeesd mfro eth prmyari mroot o,ctrxe sscro etssucaed() ta the yeldamrlu adips,rmy dan neth pssaeny at eht itenroar omrto ohnr fo the ipalsn eev.ll

uecaesB fo cotnesaisdu ta eth amrdlulye pma,rydis oyu hdousl aekm a otne fo wereh ayn tskore sr.ocuc sI it baevo eht ymlrduale sdpymrai? Tehn ti will aectff eth deis tpiosope hte osretk atocnrl)tarlea(. Is it bewlo teh ualrmdyle dymasp?ri nehT ti lwli caefft eth asme esdi sa eht eorkst .(tii)arslpael

hungrybox  Woops, E is also on the right side (also remember that imaging is looking up at someone, feet first). But a cerebellar stroke would have caused ataxia. +  
mnemonia  Very nice!! +  
usmleuser007  What gets me is that they mention that Left 2/3 of face is affected. This should indicate a non cortical innervation as most of the cranial nuclei are bilaterally innervated from the left and right hemisphere. If left 2/3 of the face is affected then it should also mean that the lesion is after CN5 nuclei. +1  
yotsubato  @hungrybox Thats not the cerebellum thats the occipital lobe. You would see leftsided homonymous hemianopsia in that lesion +8  
mrsmac  To my mind, it is simpler to consider the question first in terms of blood supply distribution. Left sided hemiparesis and weakness of lower 2/3 of face are both indicative of a MCA rupture/stroke (First Aid 2018 pg. 498). Furthermore, since the injury has affected motor function we would be considering the descending tract i.e. lateral corticospinal which courses through the ipsilateral posterior limb of the internal capsule then decussates in the caudal medulla. +1  
mrsmac  You're considering the wrong CN here. CN5 motor function involves muscles of mastication and lower 2/3 of tongue. The nerve in question in this case is CN7/VII Facial n. CNVII UMN injury affects the contralateral side, whereas LMN injury affects ipsilateral (First Aid 2018 pg. 516). i.e. before and after the nucleus in pons respectively. I hope this helps. +2  
nala_ula  Spastic means UMN lesion, since they also don't specify if there is arm or leg weakness, I didn't assume it was MCA stroke. I went with the reasoning that for there to be spastic hemiparesis, there must be damaged to the UMNs and therefore the internal capsule is where these tracts are. +  
champagnesupernova3  Omg this whole discussion is confusing. Internal capsule contains ALL corticospinal and corticobulbar fibers = contralateral hemiparesis and UMN facial lesion +22  


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I teg atth sthi weansr hcceoi si het sotm eaacmilb rea.nsw

tuB esonylth eht yaw thye kaesd teh nueqstio i"t is osmt ipaperpator fro teh iaynchspi ot aessdrd eth siesu of a gifdeen etub in iwchh fo teh lgfolniwo ensnmra"

My gensroani was: lf.b.leoee.rw eth mayifl nac even bigne ot guear wath do do dot'n uyo heav to seppoor a aemlidc nmmrt/aentetmeegtaan yrgts?tea icwhh si yhw I ntwe tihw dmnmerec"o a e"b.t..u

home_run_ball  Like what is the learning objective of this question? On first aid if you go by the Surrogate decision maker priority: you do spouse first...so like wtf nbme? +13  
uslme123  I think it's because there isn't a legally appointed health care surrogate in this case. The family hierarchy is only an "ethical suggestion." +1  
nala_ula  According to first aid, there is an order to who makes decisions when the patient is not able to and hasn't left any directives. My issue was the same as home_run_ball, since they specifically asked about the feeding tube and not "who is supposed to make decisions now" even though that is also warped since the spouse has precedence. +2  
badstudent  If you look at the wording for the rest of the recommend a tube option ("because feeding will be more efficient and prevent starvation") it seems like you would be persuading the family to move forward with a feeding tube for their ease and convenience rather than proceeding with a feeding tube to avoid the possible dangers of an aspiration pneumonia. A family that is visiting daily likely doesn't mind any challenges associated with feeding. Instead it would be more important to recommend a feeding tube to avoid risk. Dumb questions for sure, just wanted to explain why i ruled that answer out. +  


submitted by kchakhabar(46),
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hWat htrew em off ni iths qneiuots si hte pehsar l"elsc hitw ltilet lctposyma ttah ear tceiw teh iesz fo yy.ctepsmlo"h I othhug lamsl" lcle ncraaoimc" cnanot eb taht b.gi

nala_ula  Omg literally the same thought process I had, that phrase through me off! +  
nala_ula  threw* +1  
jesusisking  Super counter-intuitive but apparently SCC cells are 1.5-4x the size of lymphocytes: https://www.ncbi.nlm.nih.gov/pubmed/1313679 +1  


submitted by kchakhabar(46),
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Waht etwrh em ffo ni hsti otnuqsei is the aeshpr scll"e hitw etiltl maltcspyo htat rae itcew eht eisz fo tephoscl.ymy" I hughto amll"s lcel cranc"maio noatcn be htat big.

nala_ula  Omg literally the same thought process I had, that phrase through me off! +  
nala_ula  threw* +1  
jesusisking  Super counter-intuitive but apparently SCC cells are 1.5-4x the size of lymphocytes: https://www.ncbi.nlm.nih.gov/pubmed/1313679 +1  


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lginalLeeo is mocmon seusca of uomannpie dpiempuesosr no hcicron ttbisoevcru lypornamu adis.ees

asapdoc  Im pretty sure so is strept pneumoniae +4  
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 +4  
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. +2  
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 +1  
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 ? +5  
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... +8  
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. +5  


submitted by meningitis(544),
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ehnW nnaigsdt ,pu teh yobd nolmylar titevacas pcsytmehiat ysstem ot doavi tshitoarcot npeoyihsnto.

uBt siecn herte is won an eaiivddt fetefc fo the rtmaocphmoohoeyc eiraedrngs,c ti lwil dela ot a ernepyshitno

e.(:i ueoblD visotoartocnncis = Pohe gniscdreear + hStaicpymte se)ytms

sympathetikey  Brilliant. +5  
medschul  Would pheo have a normal resting BP though? +13  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +8  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +1  
notyasupreme  Damn llama, that is WAYYY too much of an inference. Maybe if they said she was nervous in general or something, but not everyone gets stressed out by a doctor hahaha +  


submitted by breis(50),
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oruy essug si sa odog sa ..........e.........................i....m..............n................

nala_ula  I spent so long on this question and same... hahaha +  


submitted by asdfghjkl(3),
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nAoeyn owkn hwy FI-G1 now'tuld eb racdeines sa ew?ll GRHH si duitetmals in ogylieycpmhc se.atts

nala_ula  Honestly, it's something that has confused me for a while. Why is it that GH secretion is stimulated by hypoglycemia? I mean, it's literally called growth hormone (for growth!), and hypoglycemia, which is basically a "starvation" state, will stimulate this hormone? +  
shaeking  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529368/ This might help answer your question. I basically didn't pick IGF-1 because it would increase the uptake of glucose leading to a worsen hypoglycemic state. Didn't have a true reason otherwise. +  
temmy  IGF-1 is regulated by insulin. so it will be decreased because insulin levels are also low. +2  
nala_ula  thank you @shaeking! +  
nwinkelmann  I found this and it also explains to a more genetic/cellular level. Essentially, it says that starvation induces some factors that cause GH resistance and IGF1 suppression. +1  
nwinkelmann  Sorry forgot the link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575072/ +  


submitted by thomas(2),
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Awsern si eAsy.tctro tPatnie ahs bmogiaaotlls rtf.emuimol ghutlAoh gaeimimosnn may ouccr ta tix,eenvcsio nmoaiinsmeg aer ebnign dan nfeto yocsta.timapm hyTe amy uaesc h/a ,ieszersu utb wloud be inkeyllu to aceus hated wni/ 6m of notes of ah./ The zsie of umrot nad ouesrc of nleilss is oecsnnstit with het oercus fo GMB

masonkingcobra  Above is obviously incorrect because the answer is Meningeal lol. Here is a link to a good picture: http://neuropathology-web.org/chapter7/chapter7fMiscellaneous.html +25  
kernicterusthefrog  Obviously thomas is disagreeing with the presentation of the question, and I agreed with him! This absolutely sounds like GBM, with rapid onset leading to death, and the symptoms. The question stem leads you to GBM, and the gross image to meningioma (I guess). +2  
kernicterusthefrog  Furthermore, where are the meninges on the gross image form which this (meningioma) grew?! It should at least show the tissue from whence it came! +1  
nala_ula  Had the same problem, got confused since it appeared that the growth was malignant :( +  
sugaplum  FA 2019 pg 514, also agree with everyone. weird presentation. Glios are malignant death within 1 year, meningioma are often asymptomatic or have focal signs. just a gross pathology question at this point +  
garima  ı think she died bc of pressure or something guys, its obviously round shaped benign lesion, its also extra axial not like GBM. she had this maybe years before death +2  


submitted by johnthurtjr(145),
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'Im ton a naf of rsgos atph egamis dan otuqinses ttah sya l",oko atwh is this ng?h"it - atth isda enimgnmsaio are the otsm omomcn rianb rmtou nda isht pruecit is si a dgoo lmpeeax of ne.o I ahd on daei tawh heste igntsh elokod ikel nda tgo ti gonrw, .oto aekT a loko ta tihs eno

johnthurtjr  [Here's more info](http://www.pathologyoutlines.com/topic/cnstumormeningiomageneral.html) +1  
meningitis  I got it wrong because I didn't see any apparent Dura mater nor other meninges (The veins aren't being covered by any "shiny layer"), so I thought the tumor was coming from inside the brain and not compressing it like meningiomas usually do. +3  
meningitis  But it did follow the common aspect where they are found in between divisions of brain and are circular growths like a ball. +7  
nala_ula  Since it was basically implied that the patient died and "here look at what this is" I thought it was a malignant tumor (glioblastoma)... but I guess it's all about placement. +14  
thelupuswolf  GBM would be in the perenchyma. Devine podcast said if they show you a gross picture of the bottom of the brain then it's a hemangioblastoma bc it's most often cerebellar. But this one wasn't cerebellar so I went ahead with meningioma (FA says external to brain parenchyma as well) +2  
vivijujubebe  GBM would have necrosis and bleeding whereas the ball-shaped tumor in the picture looks smooth and very benign...even tho I have no idea how someone can die so suddenly from meningioma +  
seba0039  Minor correction, but I do not think that Meningiomas are the most common brain tumor; they are the most common benign brain tumor of adults (Pathoma), but I'm not sure if they're the most common overall. +  


submitted by celeste(84),
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This susnod klei nioFacn rsmnyoed. ehT alpiroxm ltbuaur letaiplehi scell aevh a darh item nrrbsaoebgi tteifarl, so ulylo' ese a loss of ,shetphapo aonmi caisd, tbie,naacrob adn ucegol.s

medschul  Wouldn't Fanconi syndrome also cause hypokalemia though? +4  
yotsubato  Especially considering the fact that the DCT will be working in overdrive to compensate for lost solutes??? +1  
nala_ula  This question did not make sense to me at all. I knew it was Fanconi syndrome yet didn't select the obvious answer because it said "follow up examination 1 week after diagnosis". I thought it would already be in treatment... I searched (now) and it says that treatment is basically replenishing was is lost in the urine. So definitely the wording is like wtf to me +1  
sugaplum  I was thinking since it affected the PCT that Na resorption would be affected as well? But I guess the other segments will pick up the slack? +  


submitted by haliburton(214),
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AF 20:17 cnetIfs B llcse thgurho .2CD1 cAypialt tcyspmlehyo on oidlbhroeaper pl rsmea G —otn eicednft l elsBc btu eeitracv ooitcytxc T sllec. ⊕ soonopMt n dbtroapetitseehiish—elote ettdcdee yb anioggtaf lntiuo hesep ro sheor .BRUCes s of lxmcilinoia ni mnsialncnooesuoc ucase ecartrcaihsitc corualpmuplaa sa.hr

zup  misread the "accounts for" question as what's the reason for the atypical lymphocytes. So I answered "virus infected B lymphocytes." Anyone else misread it like that? +13  
nala_ula  Shit, I misread that too and I noticed it now. Nerves get the best of us! +  
stevenorange  If the question is ask what is the atypical lymphocyte in the brain , than it should be the infected B cell, RIGHT? +  


submitted by hayayah(1079),
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ihTs teapint hsa allsm cell cciarnma.o ihsT eytp fo rcnace si iscdatasoe iwth eroptiacanpsal deysosnmr suhc :as gnChsui ndoSmr,ye AISHD, ro eistaondib iantgsa +a2C clnheans Lartot)mE(aenb- or nonsr.ue faiciiopAlntm of myc eoecgsnon si oals .omnmoc

SIADH rdSmone(y fo iarpritaepopn eiantidiutrc reomonh sertcno)ei si tdeizrraaechc yb:

  • cexEeissv erfe wrtea eoerinntt
  • lomviceuE oiphnaryaetm iwth ruonireyucta nind N+a ceinotexr
  • einUr imoyltaslo t;&g rmuse ootmllyasi

doyB spoenrsd ot rwaet irtntnoee hwti nrdstaeoleo dna ANP and BNP. ahTt si whta escsau the ecdiresan rryiuna a+N eirtensco hŽwhic leads to alaztnooinmri of xclelrlaeautr diflu ovemlu andŽ het evemuocil .aapeonytmirh

hello  Why would body respond to water retention with ALDO? ALDO would increase water retention... +6  
nala_ula  @hello, the body's response is to decrease Aldosterone since there is increased volume retention and subsequently increased blood pressure. This concept confused me a lot, but I ended up just viewing it as separate responses. First, the increased volume retention leads to increase ANP and BNP secretion that lead to decreased Na+ reabsorption in the tubules (page 294 in FA 2019) and second, this increased volume basically leads to increased pressure so lets also decrease aldosterone so there is no Na+ retention (since water comes with it)... I thought it was counterintuitive to secrete so much Na+ since you're already having decreased serum osmolality (decreased Na+ concentration) because of the water retention, but I'm guessing that this is just another way our body's well intentions end up making us worse XD +35  
compasses  see page 344 FA2019 for SIADH. +  
dickass  author pasted text straight from FA but the arrows didn't copy over, inverting the original meaning +3  
medninja  The idea of increasing urine Na is getting rid of water, thats why this mechanism end increasing urine Na secretion even when there are very low serum Na levels. +