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 +1  (nbme24#35)

Does anyone have any idea on this question? Thought it was ALS.

ankistruggles  I thought it was ALS too (and I think it still could be?) but my thought process was that a lower motor neuron lesion would be the more specific answer.
sattanki  Yeah makes sense, just threw me off cause ALS is both lower and upper motor neuron problems. Corticospinal tract would have been a better answer if they described more upper motor neuron symptoms, but as you said, they only describe lower motor neuron symptoms. Thanks!
mousie  Agree I thought ALS too but eliminated Peripheral nerves and LMN because I guess I thought they were the same thing ....??? Am I way off here or could someone maybe explain how they are different? Thanks!
baconpies  peripheral nerves would include motor & sensory, whereas LMN would be just motor
seagull  Also, a LMN damage wouldn't include both hand and LE unless it was somehow diffuse as in Guil-barre syndrome. It would likely be specific to part of a body. right???
charcot_bouchard  No. if it was a peri nerve it would be limited to a particular muscle or muscles. but since its lower motor neuron it is affecting more diffusely. Like u need to take down only few Lumbo sacral neuron to get lower extremity weakness. but if it was sciatic or CFN (peri nerve) it would be specific & symptom include Sensory.

 +1  (nbme24#40)

The pt is having a severe case of pneumonia/sepsis (ARDS?), as that’s why her PO2 is low at 64. So in pneumonia there is increased capillary leakage leading to pulmonary edema.


 +0  (nbme24#30)

This one there were four odds ratios, one provided under each table. The only one that had an odds ratio greater than 1.0 was the table in the top right (Odds Ratio = 6, I believe), which when you looked at the labels, led to the right answer.


 +8  (nbme24#5)

Muscle pain + periorbital edema is a classic presentation for trichonella spiralis. Best diagnosis for this is a muscle biopsy, as the wormy likes to hangout within the muscles.

sympathetikey  That's what you get for killing polar bears.
dr.xx  That's what you get for not cooking them well.
charcot_bouchard  Theres nothing called "well cooked polar bear meat"

 +11  (nbme24#49)

Apparently there is a completely separate spinal cord reflex where direct penile stimulation leads to an erection. This reflex only needs an intact arc in S2-S4, so as long as this region is not injured, an erection can still occur. However, with transection at C8, then the psychogenic erection reflex cannot occur, as this requires descending fibers from the cortex.

lsmarshall  Just saw a good summary of nerves/vessels involved saying, "pelvic parasympathetic fibers from S2-S4 can cause cavernous arteriole vasodilation via the cavernous nerve without of central stimulation."
seagull  S2-3-4 keeps the penis off the floor
drdoom  Modifying @seagull into iambic pentameter: “S2, S3, and Number 4 / keeps the big ole penis / off the floor”

 +2  (nbme24#8)

Can’t help much on the exact reasoning why, but there are a few UWorld questions on this where if a neonate has hypoglycemia, ketosis and hyperammonemia, a organic acid disorder should be suspected (propionic acid or methylmalonic acid). Less suspicious of an RTA cause hypoglycemia is not characteristic of that.

sweetmed  Im assuming because N-acetylglutatmate is an allosteric activator of CPS I needed in urea cycle. and N-AG is made of glutamate and acetyl coA. So in organic acidemias, all the acetyl CoA is being used to make ketones for energy since gluconeogenesis is messed up. So Urea cycle doesnt work as well and NH3 accumulates

 +4  (nbme24#39)

There are two mechanisms of regulating renal blood flow, the myogenic mechanism and tubulo-glomerular feedback. This question asks purely about the myogenic mechanism, which is where the afferent arteriole controls blood flow based purely off blood pressure entering the kidney, which is why decreased afferent arteriolar resistance is the best answer (the arteriole is dilating in response to the decreased blood flow in attempt to maintain normal blood flow to the kidney).

nwinkelmann  Man... I took this WAY TOO FAR, lol. I totally didn't recognize the clue of GFR and RPF as staying the same to tell me it was talking about normal, physiologic autoregulation. Silly mistake!




Subcomments ...

submitted by sattanki(31),

Does anyone have any idea on this question? Thought it was ALS.

ankistruggles  I thought it was ALS too (and I think it still could be?) but my thought process was that a lower motor neuron lesion would be the more specific answer. +  
sattanki  Yeah makes sense, just threw me off cause ALS is both lower and upper motor neuron problems. Corticospinal tract would have been a better answer if they described more upper motor neuron symptoms, but as you said, they only describe lower motor neuron symptoms. Thanks! +1  
mousie  Agree I thought ALS too but eliminated Peripheral nerves and LMN because I guess I thought they were the same thing ....??? Am I way off here or could someone maybe explain how they are different? Thanks! +  
baconpies  peripheral nerves would include motor & sensory, whereas LMN would be just motor +6  
seagull  Also, a LMN damage wouldn't include both hand and LE unless it was somehow diffuse as in Guil-barre syndrome. It would likely be specific to part of a body. right??? +  
charcot_bouchard  No. if it was a peri nerve it would be limited to a particular muscle or muscles. but since its lower motor neuron it is affecting more diffusely. Like u need to take down only few Lumbo sacral neuron to get lower extremity weakness. but if it was sciatic or CFN (peri nerve) it would be specific & symptom include Sensory. +  


How do you know he has an incarcerated inguinal hernia and not fecal impaction?

sattanki  So as far as I understand, you don’t really get a bulging, defined abdominal mass with fecal impaction. Much more likely to see this with a hernia. +2  
xxabi  Fecal impaction can be palpated in the abdomen, since it'd be accumulating in the rectum and colon, not the groin. Hope that helps! +5  
pseudorosette  a little late but they also mention that the mass had bowel sounds hence it was an incarcerated bowel! :) +2  


Why are the IMA and SMA most likely to be affected in her condition?

sattanki  Again, not too sure, but I think they were describing a patient with chronic intestinal angina, which is classically from atherosclerosis of the IMA/SMA. +1  
mcl  I was also thinking about which areas have crappy blood supply (watershed areas), which I assume would be worse off in the case of chronic mesenteric ischemia. If you look on page 357 of FA 2019, SMA & IMA at the splenic flexure is a watershed area; the other is rectosigmoid junction (sigmoid branch from IMA and superior rectal). +  


Why is basal keratinocyte : suprabasal keratinocyte the cell junction that’s most likely to be affected? Is it because it’s the only answer that lists a junction between two keratinocytes?

sattanki  Not too sure on this one, but I interpreted the basal keartinocyte:suprabasal keratinocyte as the stratum spinosum region, which is known to have the most desmosomes. +  


How do you know her pulmonary symptoms are due to pulmonary capillary leakage and not hypoventilation? Is pulmonary capillary leakage just another way of saying pulmonary edema?

sattanki  Hypoventilation in no way leads to pulmonary edema. +  
fenestrated  Hypoventilation would increased the PCO2 +