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Contributor score: 46


Comments ...

 +2  (nbme24#13)

question is asking what's the best next step not necessarily what is the best diagnostic step, which is somewhat of Step 2 rotation shelf question (for people who takes Step 1 after rotations). TLDR, best NEXT step is talk to her first at minimum you need to determine if she has capacity.

While the patient has pretty bad MMSE:

B. Is the best next step. You need to discuss with her first. => determine her decision making capacity => then proceed whether to discuss with her daughter (A).

Lumbar puncture is the best diagnostic step. However, in this question they're asking you what you need to do to even proceed to this step. I.e. get her capacity then you can proceed to lumbar. This is because lumbar puncture is more invasive and you'll need to assess capacity as well as get either her (if she has capacity) or daughter.





Subcomments ...

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kahTn oyu BNEM orf het ighh utyiqal urpsc.eti It samek steeh sxema restss erfe adn y.onleeajb

sympathetikey  Feels bad man. +3  
zoggybiscuits  Those Sclera sure look blue. wow. +20  
yotsubato  the same girl shows up on so many NBME exams its not even funny. Its just like that poor kidney that's cut in half that shows up in all kidney questions. +13  
aneurysmclip  I turned my brightness up and down 2 times to make sure it wasn't my brightness messing with the sclera. I'm declaring it, NBME stands for "Naturally Bad at Making Exams" . +6  
peqmd  $60 a pop and no competitors...That's what happen when there's a monopoly. +5  
peqmd  Actually they used their best software to generate images. You might have heard it before, it's called MS Paint. Quite legendary. +7  
feochromocytoma  It feels like they cranked up the contrast and saturation on a normal eye to make it look "blue"... +5  
rockodude  everyone hates on nbme, but they're showing you a picture zoomed in of her eyes and she has a history of multiple fractures/bad wound healing at the age of 4, I feel like OI should at least be a consideration based on the overall clinical picture +1  
feochromocytoma  Yeah I got it right, it's just funny that they don't use higher quality pictures for the exam +1  
djeffs1  that is clearly a malar rash... oh wait nvm just pixellation +3  


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hnkTa oyu MBNE orf het hghi tqyulia rciptsu.e It maske ehest saxem tsssre erfe nad ja.enyboel

sympathetikey  Feels bad man. +3  
zoggybiscuits  Those Sclera sure look blue. wow. +20  
yotsubato  the same girl shows up on so many NBME exams its not even funny. Its just like that poor kidney that's cut in half that shows up in all kidney questions. +13  
aneurysmclip  I turned my brightness up and down 2 times to make sure it wasn't my brightness messing with the sclera. I'm declaring it, NBME stands for "Naturally Bad at Making Exams" . +6  
peqmd  $60 a pop and no competitors...That's what happen when there's a monopoly. +5  
peqmd  Actually they used their best software to generate images. You might have heard it before, it's called MS Paint. Quite legendary. +7  
feochromocytoma  It feels like they cranked up the contrast and saturation on a normal eye to make it look "blue"... +5  
rockodude  everyone hates on nbme, but they're showing you a picture zoomed in of her eyes and she has a history of multiple fractures/bad wound healing at the age of 4, I feel like OI should at least be a consideration based on the overall clinical picture +1  
feochromocytoma  Yeah I got it right, it's just funny that they don't use higher quality pictures for the exam +1  
djeffs1  that is clearly a malar rash... oh wait nvm just pixellation +3  


submitted by jkan(23),
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-tecidepp si owl with egouxneos slnun.ii epct(e-ipd made as a rydctpubo fo nsiulin uotocdinrp ni teh tayrd)oedpbee iv+isst ghhi slloinwi+nu pe=pie-ctd uoesoxneg siunnil b.suae In a &ldcg;thi- tsifctaiou yb xypro

sunshinesweetheart  ugh, I feel like a child could misuse their insulin by accident without proper supervision. Totally thought she had T1DM and not enough guidance on how to use the meds. annoying +3  
peqmd  I couldn't rule out if the child was trying to get swole and had a shady dealer. +3  
alwaysdivs94  Sorry, where doesn't it talk about insulin abuse in the question? I thought she was administered for an acute exacerbation of heart failure? +  


submitted by dragon3(12),
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I tsolma edpikc nskgia hte oormtmea tno to somke in teh ntaam,rtep tub then I rudigef st'ath ebyndo the opsec of teh ocor..dt. raoenth rspoen idas kagtni iotesdsr dolwu eb oot cuhm fro wo,n adn I pesusop htsat' eescuba het mhaats si crlnollowl-deet whti erh lhaenri r?n aht't(s hatw I ahd pdekc)i

sherry  I would say the patient's asthma only got worse after her moving out. So its more allergen-related. Getting rid of the allergen is always better than upgrading medications. +2  
et-tu-bromocriptine  Rippp the "don't be a dick" strategy definitely failed me on this one. For some reason, I thought requesting the patient to ask someone else to change their smoking habits would be a tad too much. I can just picture UWorld smacking me with a "Although it is likely that the roommate's cessation of smoking could alleviate the patient's asthma exacerbations, this request would be out of the physician's scope....etc." +41  
peqmd  Depends who's dickier the doctor telling the patient she shouldn't live in smoke or some guy smoking in the house +  


submitted by neonem(571),
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heTse ear uotg .tasscyrl I oppeuss teh sebt ywa to nreideteaiftf siht scea fmor ptooguseud is atth eth ayrlcsst rea rphas a&m;p neepahdlde-es and tno eprdbhshdoiao.m-

sympathetikey  Yep. They tried to throw you off with the picture, but the wording in the stem says its a "photomicrograph" -- not exposed to plane polarized light, where you would see the negative birefringence. +18  
linwanrun1357  Why is NBME so mean to us. Do those mean a lot in clinic? +  
suckitnbme  @linwanrun1357 I highly doubt you would be looking at your own joint fluid aspirates instead of sending it to the lab. +3  
nnp  what those yellow white nodules signify? +  
peqmd  In clinic gout is typically a clinical diagnosis. If you can treat w/ NSAIDs instead of aspirate you would do that. You would aspirate if you are considering septic arthritis so you can get culture. I don't think anyone aspirate for heck of it. +  
lowyield  @nnp, the yellow white nodules are tophus which is a sign of chronic gout, characterized histologically by aggregates of uric acid crystals, can show up as skin nodules most commonly on external ear, olecranon bursa or achilles tendon (pg 467 FA 2020) +  


submitted by drpatinoire(13),
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I tsju anwt ot tnimoen atth sdki tiqnatugs is yrev cuhm tunggsgies a FTO ni UEo.MLl.l.S Adn her mypoalnru mrmruu gsgusste oynarplmu snotes,is hwich ftruerh ussorppt OF.T

peqmd  Not necessarily. Squatting just helps to increase preload => this will expand the left cardiac chambers and reduce R->L shift. It's a general principle to R->L shunt heart defects not specific to one disease +  


submitted by sympathetikey(1358),
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yrttPe rrs,fhwodtrgatai ubt a oodg imdrener ahtt oilyeriomssfb acn uaces an aedglner psn.eel

sympathetikey  Due to extramedullary hematopoesis +25  
zoggybiscuits  I thought it was spleen but the fact that hematocrit was 24% 4 HOURs later made me think otherwise. It was my understanding that the spleen would bleed you out quick! +  
need_answers  couldn't also be ruptured spleen because they said intraperitoneal fluid and everything else is retroperitoneal ?? +1  
peqmd  Spleen is most commonly ruptured in blunt trauma so along with myelofibrosis and being kicked on the left side it's just asking to be ruptured +2  
limberry  @need_answers the bladder is intraperitoneal, not retro +  
limberry  bladder is sub*peritoneal, sorry +  


submitted by dbg(151),
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idD naoeyn sele odernw HAWT YROL"UNMPA SYO"SPMMT si eth usoqitne rnigefrre o?t? eTreh is tlrallyie not a sniegl mtmsypo eienmotdn ni hte lewoh eetgvi.nt No ckrl"scae rhead reov btho nugl lsfdei" aer tno .mstypmos Tyeh rae gnsis dofnu by the ipcyain.sh

elrSyious otibngdu hte holwe BMEN borda estt irtresw ightr now. Do ehyt eaultdyqea iseevr hetri ?rokw hiTs si nto the srtif atlnciche tmaekis I zealire on the wne smro.f

nbmehelp  Yup. Looking back its clear what they were trying to get at, but this definitely threw me off when I was taking the test bc I kept rereading the question looking for a specific symptom the pt had that they wanted me to explain. +2  
ergogenic22  I agree with you that the writers are whack but this question clearly says "diffuse crackles are heard over both lung fields" +2  
ergogenic22  i take that back i understand what you're saying +5  
peqmd  I think what are causing her pulmonary "signs" might be more accurate question. https://www.medicalnewstoday.com/articles/161858#sign-vs-symptom +1  
an_improved_me  I get where you anger is coming from.. They expect the students to pick up the most minor details as they may be relevant to an extremely vague and tedius questions and answers, but don't hold themselves to the same standard. +  


submitted by neonem(571),
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hisT etainpt t'nis al,nngyvoititehp 'teehyr tnilRtYHvnigaEeP, enehc het 2POC t;l& 40 mm gH.

'stLe lkwa ti wabscdra:k ehyT rea gvyirtenpnaielth to epeatomcsn orf eth tceablmoi ciisaosd daeucs by sedwiaerpd ahx.poiy nipeHeatvgtyirln sowlal yuo ot bwol off moer .C2O

hyW rae yhet cx?ohiyp eTh pesorn si hyopcix ude ot nlnmmifoatai adn uatce arypesotrir rstdssie myronsed rofm teh e.anpuniom llA het nkiocyest fomr eth ylmioarmantf lecsl uscea ncridseae pmauyonlr ylaclirpa ,kealega icwhh csolbk pu eht eoallarv nrmeeamb os that O2 'ncat tge hotgrhu ot het oldbo.

Why do tehy vaeh acebitmlo odiacssi in the rtsfi ae?lcp oN xogyen >-- on otnclree nosttprra cahni dan no ATC t-;-g& icclat codss.aii

diabetes  no pneumonia it is UTI +3  
makinallkindzofgainz  The infection from the UTI spread to her lungs +  
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1  
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +17  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +3  
thisshouldbefree  she has an increased A-a gradient. +  


submitted by colonelred_(105),
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oLkedo ti pu nda dfonu thta esbucea ryoe’u ni a seipun ospintoi rof a lgon teim yrue’o oigng to vhea nresecdai nsveou trnuer ichwh delsa ot scneerdai O.C sihT itvgleanye cdkefbaes no ,AARS nglaedi ot edaescdre sralet.nodoe As a su,etrl euyor’ gngio ot ehav sedarcien usriiesd hchiw aseld to erceddaes odblo dna lmasap lvoemu.

medstruggle  Doesn’t supine position compress IVC leading to decreased venous return? (This is the pathophys of supine hypotension syndrome.) There was a UWorld questions about this ... +4  
tea-cats-biscuits  @medstruggle *Supine position* decreases blood pooling in the legs and decreases the effect of gravity. *Supine hypotension syndrome*, on the other hand, seems specific to a pregnant female, since the gravid uterus will compress the IVC; in an average pt, there wouldn’t be the same postural compression. +8  
welpdedelp  this was the exact same reasoning I used, but I thought the RAAS would inactivate which would lead to less aldosterone and less sodium retention +3  
yotsubato  You gotta be preggers to compress your IVC +5  
nwinkelmann  Could you also think of it in a purely "rest/digest" vs "fight/fright/flight" response, i.e. you're PNS is active, so your HR and subsequently your CO is less? But the explanation given above does make sense. Also because I think just saying someone is one bed rest leaves a lot up for interpretation, maybe not with this patient because his pelvis is broken, but lots of people on bed rest aren't lying flat.... ? +1  
urachus  wouldnt low aldosterone cause low plasma sodium? choice B +5  
kpjk  could it be that, while low aldosterone levels decrease plasma sodium levels- there is also decrease in blood volume(plasma),so there wont be a decrease in the "concentration" of sodium +4  
almondbreeze  FA 2019 pg 306 on Lt heart failure induced orthopnea - Shortness of breath when supine: increased venous return from redistribution of blood +  
almondbreeze  if there was no HF, it would lead to increased CO --> decreased aldosterone +  
theunscrambler  @peqmd thanks for sharing that. According to the presentation, the diuresis via ANP occurs (along with sodium), which is followed up by an increased in RAAS --> maintains sodium levels. This cycle can then continue. Slide 13. +  
jj375  @urachus - Either BB or Sattar taught me this but I feel like it is often forgotten. "RAAS/Aldosterone affects blood volume, and ADH affects Na level". So Increasing aldosterone will increase blood levels however water follows the sodium so you will not get a change in sodium levels. ADH however does affect Na since aquaporins are bringing in water without affecting sodium levels. +  


submitted by eli_medina9(18),
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ACELILL OENHGETRYIEET F(A apeg 75 1920)

eheTsr teipmull lellae inatsavr orf teh CRTF egen ni a silgen ocsul, os oyu ucldo tge scitcy ifrbisos fmor a tmantuoi in nay oen fo ohset lleela ahsaensrvtier(t vero 0501 rifendeft tsiutonma sidbdcre)e teh eonsqtui mtes enentidom yeht teetds fro hte msto conmom ,estpy so ew nca esasum ehty brlyboap just siesmd stgtnie fro aotsntium in otrhe ele.slla

melanoma  in other alleles?, we only have two alleles per gene +  
qiss  @melanoma "other alleles" as in the same allele with a different type of mutation. Like eli_medina9 mentioned, CF simply can be caused by thousands of different mutations of the CFTR gene. This baby girl has two alleles, one of them with a mutation found in the analysis and the other allele with a mutation that wasn't detected amongst the most common mutations. +  


submitted by usmile1(109),
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uaoMemnbrs ypoeaphrnht nda lmamnii ehncga essaide nca be iyalse lerud otu sa heyt rea hicrotpne srrotyuseuinaso tbiTeimltl.nd trshieipn (aka ctaeu irlntittiaes eirhi)tpns anc be redlu uto sa ti csuaes WCB assct ont RCB as esne ni itsh o.snuteiq ar lapPlyi nsocesir - rheeit has no sacts ro ti tmhig hwos WBC tacss but nto CBR ueacbse eht loermpb si otn in eht llgouer.im

taelb fo eceaurlotnnm on pgea 825 axlipnse taht iirvepoaerltf utjs anems peyhr clrellua olgl.emiru ne viG teh ptsnatei trhoyis fo oers rothat wto sweek gao, nwo nietnrpegs hiwt cNtiepihr morndSye thiw CRB tssa,c fvetileorpiar oihtumnleolrrsgiep is hte nlyo rblesaoane arswen.

medguru2295  This was my precise login. I wound up getting it by elimination. But, didn't like that answer as its uncommon in small children and the child seemingly had no risk factors. +  
thotcandy  @medguru2295 FA says it's most commonly seen in children and it's selflimited vs adults is rare and can lead to renal insuff +  
peqmd  They're using the broad category for PSGN, Pathoma pg 130 IIC. PSGN = Hypercellular, inflammed glomeruli on H&E stain and cross referencing the FA table mentioned hypercellular => Proliferative. +5  


submitted by medstruggle(12),
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Why is ti tno naaovir iloflelc e?lscl I uthghto the lameef agalno fo lrStoie adn egydLi si sotgrahen/cuaal ecs.ll

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +9  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +4  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +11  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +3  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +38  
mcl  But seriously though, pathology outlines says sertoli-leydig tumor "may be suspected clinically in a young patient presenting with a combination of virilization, elevated testosterone levels and ovarian / pelvic mass on imaging studies." As for follicle cell tumors, granulosa cell tumors usually occur in adults and would cause elevated levels of estrogens. Theca cell tumor would also primarily produce estrogens. Putting the links at the end since idk if they're gonna turn out right lol Link pathology outlines for sertoli leydig granulosa cell tumor theca cell tumor +12  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +5  
medpsychosis  So after doing some intense research, UPtoDate, PubMed, an intense literature review on the topic I have come to the final conclusion that...... ...... ...... ...... Wait for it.... ..... ..... Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +9  
charcot_bouchard  Hello, i just want to add that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
giggidy  Hold up, so I'm confused - I read all the posts above but I still am unsure - are sertoli-leydig cells notorious for producing androgen? +4  
subclaviansteele  Hold the phone.....Females can get sertoli leydig cell tumors which are notorious for producing androgen? TIL TL;DR - Females can get sertoli leydig cell tumors = high androgens +  
cinnapie  I just found a recent study on PubMed saying "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +2  
youssefa  Hahahahaha ya'll just bored +9  
water  Bored? you wouldn't think so if you knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +5  
nbmehelp  I dont get it +  
redvelvet  how don't you get it that females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen? +1  
drmomo  what if this means..... females can get Sertoli Leydig cell tumors, which are notorious for producing lots of androgen +  
sunshinesweetheart  hahahaha this made my day #futurephysicians #lowkeyidiots +  
sunshinesweetheart  @medstruggle look up placental aromatase deficiency (p. 625 FA 2019), it would have a different presentation +  
deathbystep1  i am sure i would ace STEP 1 if i only knew that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
noplanb  Wait... I might actually never forget this now lol +3  
drmohandes  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +1  
lilmonkey  Don't forget that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! You're welcome! +  
drpatinoire  Now I get it that females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens. Thank you very much.. So why choose Sertoli-Leydig cell tumor again? +  
dr_ligma  The reason is because females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of androgens! This is easy to remember, as you can remember it through the simple mnemonic "FCGSLCTWANFPLOA" which stands for "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen!" +18  
minion7  after receiving a f*king score..... this post made me smile and thanks to the statement-- females can get sertoli-leydig cell tumours, which are notorious for producing lots of androgen! +1  
djtallahassee  My worthless self put adrenal zona fasciculate but now I will never forget that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +1  
medguru2295  Wait..... so can females get Sertoli Leydig cells that produce androgens then?????? +  
peqmd  Going to snapshot this to my anki deck card: "females can get Sertoli-Leydig cell tumors, which are notorious for producing lots of {{c1::androgens}}" +1  
paperbackwriter  Watch me f*ck up the fact that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgens on the real deal. +2  
alexxxx30  just made sure to add to my notes "Females can get sertoli leydig cell tumors, which are notorious for producing lots of androgens" +2  
peridot  I also just wanna add that if you look on in FA on p.696969, you'll see that they'll mention "Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen" +  
mbate4  According to the literature [lol] females can get sertoli-leydig cell tumors, which are notorious for producing lots of antigens +  
drdoom  the tradition lives on +1  
jamaicabliz  Wait... so for clarification, is it that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen? Or that Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen?? HELP +  
abkapoor  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen sorry for bad Englesh +  
faus305  Sertoli-leydig cells are notorious for producing lots of androgens, females can get these. +  
djeffs1  the fact that a bunch of medstudents can get so weird about how females can get sertoli-leydig cell tumors: notorious for producing lots of androgens- just made my week!! I love you guys +  


submitted by happysingh(45),
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so, eht yeK sdwro ttha no eno si inoitnngme : cnamgutconmii ldoahuprehsyc

hte shhtapopy ogse elik tshi :

an rmyamilnotaf isttgen (,ie.. cbusordanahi ma)oergerhh leyid ssirfiob / iansrcgr fo teh cadanorih nrgasuitloan g;&t= peimidar CSF negdraai

teh eky ntiops / ecnptocs etyh rea rtgiyn ot etst rhee : .1 od yuo nowk thaw mctuncmnigaoi udrhspclhyoea hi(otwut mthe tlilegn you soeht s)owrd .2 do oyu onwk hws'at teh pphghalysiootyo (of ingiumnccoatm uypshr)daelcho si ?

potentialdoctor1  Exactly. To add to this, communicating hydrocephalus can be subdivided as follows: Normal-pressure hydrocephalus: Chronic/gradual decrease in CSF reabsorption at arachnoid granulations, usually due to calcification due to aging. CSF accumulates slowly, so ventricles are able to widen without causing an important increase in intracranial pressure. Symptoms occur due to compression of periventricular white matter tracts ---> Wacky, wobbly, wet High-pressure hydrocephalus: Acute decrease in CSF reabsorption at arachnoid granulations, usually due to inflammatory state in the subarachnoid space (eg, meningitis, sub-arachnoid hemorrhage). CSF accumulates suddenly, causing an acute-onset increase in intracranial pressure +7  
sunshinesweetheart  not to take away from your perfect explanations, but if it were a woman with neck stiffness and fever (rather than circle of willis rupture) that could lead to increased CSF production, right? I think that's the only case where CSF production would increase. Also I think decr absorption in arachnoid granulations in that situation as well so it'd be a shit question +  
peqmd  If anyone like me also got "decreased absorption in choroid plexus", as their wrong answer it's because the choroid plexus doesn't "absorb" it produces. +9  
alienfever  FA 19 p510 +2  
alienfever  If anyone chose F, communication hydrocephalus is caused by decreased absorption and not increased production. FA 19 p510. +1  
an_improved_me  So she has a leaking aneurysm for how long.. gets it repaired, and then within 2 days has an inflammatory response that leads to decreased CSF absorption at arachnoid granulation... Is it the bleeding associated with the aneurysm causing it? The surgery? I'm inclined to say the latter, given that it happens coincidently after the surgery, and not for however long it was leaking beforehand. Thats what tripping me up. +  


submitted by hayayah(1079),
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eH ash falec nntiienccnoe so hsi erlteanx sctpihnre is ,adgmeda ichhw si iventenard by the peaudldn .n (S.4S)2- ehT elipcv nnsaichlcp verne,s hchwi emtidea the nterieoc ,erpssoc rea also SS-42.

thomasburton  Why could this not be dysuria? +3  
lilyo  I think that you are thinking about urinary incontinence. If we damage the pudendal nerve S2-S4, you can exhibit urinary and fecal incontinence since this nerve innervates both the urethral and the external anal sphincters. However since the pelvic splanchnic nerves also have roots that originate in S2-S4 a patient with pudendal nerve damage will also have impotence since these control the erection reflex. He wouldn't have dysuria which is painful urination. Most likely caused by a urethral infection or a blockade of the urinary tract. He would have urinary incontinence. I hope this helps. +16  
alexxxx30  dysuria is painful urination...if it said urinary incontinence then you'd be right. But decreased innervation wouldn't cause pain (that would mores be associated with UTI) +3  
peqmd  Another approach is fecal incontinence => parasympathetic nerve dysfunction => no boner +  
dul071  ahhhhh fucked up with terminology again thinking dysuria was urinary incontinence +  


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eroInfdm cetnnso udlhos eb aenotdib yb a drvorepi owh ash ucneitfisf eelndwkog ot gevi na cacarteu npirdstcieo fo hte toen,nveinitr eth skri nad ,entsebif avtreltnaie tmtntersae nda to nwreas all of hte tsi'npeta qutoissne

stinkysulfaeggs  Hate this question though... the first thing you would have to do in this situation is refuse to do what the resident asks you to do. Then you could accompany them.... +10  
peqmd  If not for the additional "refuse to sign consent". I think the answer would have been extremely straightforward. +1  
dyckim4  I was taught that that the person who is operating should get the consent that's why I got this wrong.. +1  


submitted by divya(59),
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ayko tub reehw ni eht nesotqui is it ngkasi hehetwr sit' neinnitto ot rteta ro per ctlpooro or sa dtaeetr???

rea we to msseua sit ITT if htye dton' monntie nighnyta or the trap of eht sueoitnq hatt yssa i"pmayrr "saaniyls het gwyeiva ot ?T?IT

kpjk  I had the same doubt. I think if we were to consider "per protocol" then answer would have to be a mash of options A and B. There is no option that would be right for per protocol +  
peqmd  I think ITT is assumed b/c it's the one that has reduced biased in measurements. +  


submitted by dumbo123(2),

I think its because she has a hx of peptic ulcer disease (stated in hx) that is currently flaring up (mild epigastric tenderness to deep palpation).

There are drug interactions--- Atorvastatin (choice A), which is a CYP3A4 substrate, shouldn't be used with Clarithromycin/some other antibiotics used to tx peptic ulcers/CYP3A4 inhibitors.

Under warnings and precautions, page 1, FDA- https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020702s056lbl.pdf https://www.pdr.net/drug-summary/lipitor?druglabelid=2338

(I also got the questions wrong and chose Atorvastatin-- this is just my guess!)

peqmd  Agreed got the question wrong too...Here's what I got from Dr. Uptodate DDI. TLDR Increased risk of Rhabdo is worse than increase risk of gallstones. "Concurrent use of clarithromycin or erythromycin together with simvastatin, lovastatin, or atorvastatin was associated with an increased risk of hospitalization for rhabdomyolysis (RR=2.2), acute kidney injury (RR=1.8), or all-cause mortality (RR=1.6), as compared to concurrent use of azithromycin with the statins" +