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NBME 20 Answers

nbme20/Block 3/Question#37 (31.9 difficulty score)
A 62-year-old man with alcohol-induced liver ...

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submitted by sweetmed(123),
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A pidar trodinuce of eaicsst si efnot dsomalpcecih iplsmy itwh eht ianodtdi of owsedo-l oarl tuiidercs ni eth aonietpttu tntgesi. nl-isrteiF ciriuted htaryep fro ciotchrir stiaces is hte obinmcde eus fo oontesncplraio dltAan)(coe dan srmuoieedf ix(a)Ls - valldneC nlciiC

 +2  upvote downvote
submitted by hayayah(989),
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ilCcialn esu fo rKigp-nsa cii:suetrd

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redvelvet  Patients with hepatic ascites have hyperaldosteronism; because the intravascular volume is escaped to third space(ascites). So adding spironolactone is a good choice. +2  
champagnesupernova3  Always combine a K+ losing diuretic with a K+ sparing diuretic +9  
bryno20  My rational was a bit different. The patient likely has hepatorenal syndrome leading to a the ascites and decreased GFR. All diuretics, except for the steroids (eg, spironolactone), require secretion into the PCT in a GFR-dependent manner; for this reason, patient's with renal impairment show best success the steroid diuretics since their action is independent of renal function and GFR. +