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Welcome to drmohandes’s page.
Contributor score: 73


Comments ...

 +6  (nbme24#37)
  • total T4 (or T3) = free + TBG-bound
  • pregnancy β†’ TBG increase β†’ TBG-bound T4 increase β†’ free decrease β†’ less negative feedback β†’ more TSH β†’ restore free T4 levels
abhishek021196  Very simple explanation. Thank you +

 +5  (nbme24#30)
  • SIADH β†’ euvolemic hyponatremia β†’ normotensive / hypertensive
  • ACTH increases cortisol β†’ hypertension (alpha-1 upregulation & cortisol can bind to aldosteron receptors at high concentrations)
  • ACTH increases aldosterone β†’ hypertension + hypokalemia (K+ dumped in collecting duct)

If patient -only- had hypertension: ACTH more likely than SIADH.

Patient with hypertension AND hypokalemia: 100% ACTH.

Don't feel bad friends, I also had this question wrong :(...

rolubui  ACTH does NOT act directly on the zona glomerulosa to increase Aldosterone. ACTH acts only on the zona fasciculata to increase cholesterol and zona reticulata to increases sex hormones. +2
rolubui  NOT cholesterol I mean cortisol in zona glomerulosa +

 +2  (free120#31)

36 hour surgery:

  • perforated bowel
  • multiple facial reconstruction
  • ORIF of left femur

...oral acetaminophen is not gonna cut it after major surgery. Also, our opioid crisis is mainly due to overprescription/misuse in chronic pain patients.


 +3  (nbme22#9)

Some extra thoughts on distinguishing between Roseola/Parvo. I was a little thrown off by the:

  • fever since 1 week
  • rash since 4-days
  • my brain β†’ rash after 3 day fever = Roseola

_

However, if I had read more carefully:

  • rash did not spare face
  • no mention that fever was gone after 3 days, might still have fever
  • 5-year old boy; Roseola usually in 6m-2year old.

 +0  (nbme22#1)

Newly born β†’ ligament of Treitz on the wrong side β†’ something went wrong with rotation...

In the 10th week the midgud rotates 270 degrees counterclockwise around the superior mesenteric artery (FA2019 pg352).


 +4  (nbme22#49)

Countertransference (FA2019 pg. 542) = doctor projects feelings about formative or other important persons onto patient (e.g. Epstein didn't kill himself).

baja_blast  They really had mercy here by not also including Transference as an option.... phew. +

 +14  (nbme22#15)

Finger flexion done by:

  • FDP = flexor digitorum profundus (flexes DIP)
  • FDS = flexor digitorum superficialis (flexes PIP)

_

Innervation:

  • FDS 2/3/4/5 by median (C5-T1)
  • FDP 2/3 by median (C5-T1)
  • FDP 4/5 by ulnar (C8-T1)

_

Our patient can't flex DIP of ring finger β†’ FDP4 β†’ ulnar β†’ C8-T1.

Only possible answer we can pick is C8.


 +3  (nbme22#28)

Iron accumulation causes free radical damage in organs:

  • liver β†’ dysfunction / ascites / cirrhosis
  • pancreas β†’ glucose intolerance (diabetes)
  • heart β†’ cardiac enlargement (LVF can leads to prominent pulmonary vasculature)

Also notice patient + older brother are >40, which is when total iron body accumulates enough to cause symptoms.


 +4  (nbme22#30)

Primary olfactory cortex is located in the temporal lobe.

clickhere

rockodude  I feel pretty dumb for not knowing where smell is processed in the brain at this point in my medical education. Glad I learned it now! +

 +4  (nbme22#45)

Our patient has a metabolic alkalosis with (partial) compensatory respiratory acidosis.

_

Metabolic alkalosis β†’ H+ loss or HCO3- gain:

  • vomiting: lose H+ (and lose K+/Cl-)
  • loop diuretics: lose H+ (and K+)

_

Metabolic acidosis, possible causes in this context:

  • diarrhea/laxatives β†’ lose HCO3- (and K+) ; Cl- compensatory increase (normal anion gap)
  • acetazolamide β†’ lose HCO3- (and K+) ; H+ also decreases but not enough to overcome the alkalosis caused by HCO3- loss
  • spironolactone
snripper  This makes sense, thanks! +
dysdiadochokinesia  I was able to break it down to diuretic or alcohol use and chose alcohol use under the assumption that the patient's serum Cl- levels were low (90; N = 95-105) since Cl- is also lost with vomiting. Im assuming that it was wrong for me to make the association between alcohol use and vomiting. +
avocadotoast  @dysdiadochokinesia I think we can rule out alcohol use by looking at our patient's history and demographic. A 16yo girl who is dieting and constantly studying probably isnt getting turnt because 1) alcohol has empty calories (defeats the point of dieting), 2) why would you try to study when you're drunk, 3) where will this 16yo in social isolation get alcohol +

 +0  (nbme22#32)

You mostly lose HCO3- and K+ in stool.

Loss of HCO3- leads to a normal anion gap metabolic acidosis (FA2019 pg. 580 'HARDASS'), in which we also see a compensatory increase in Cl-.


 +0  (nbme22#1)

Here we go:

  • decreased LV contractility (bilateral crackles)
  • decreased cardiac output
  • activate RAAS β†’ ADH
  • increase sympathetic activity β†’ more RAAS β†’ more ADH

 +2  (nbme22#47)
  • DIC, unlikely: PT/PTT normal; wouldn't just see gum bleeding
  • hypersplenism: would cause anemia
  • iron deficiency: anemia
  • vitamin C deficiency: wouldn't cause thrombocytopenia
  • von Willebrand disease: mixed platelet/coagulation disorder β†’ would cause deep joint bleeding instead of mucosal membrane bleeding. Inherited (Autosomal Dominant), would see symptoms before. PTT can be normal/high.
beto  Bleeding symptoms in von Willebrand disease tend to occur in mucous membranes. deep joint bleeding is rare +1
castlblack  New onset bleeding? Immediately rule out vWD! +
waterloo  Vit C def I thought was super tricky. My knee jerk reaction was oh easy bruising, bleeding from gums that's what it has to be. But yeah, I think low platelet is key here. +
nafilnaf  Platelet count would be normal in vWD because there's nothing wrong with the platelets themselves. +1

 -2  (nbme23#37)

I tried to calculate it more precise, and messed up the answer...

Here is why:

  • 99.7% CI = 3 SD
  • However: 99.0% CI is actually 2.5 SD (or 2.57 if you want to be more precise)

1 SD = 1.5 mmHg β†’ 2.5 SD = 3.75 mmHG

This results in a 99% CI of 109.25 (113-3.75) to 116.75 (113+3.75)

Closer to answer C than B.


 +3  (nbme23#26)

Case = Middle-aged female with severe hypertension (180/120 mmHg), and an aneurysm.

(1) Main cause of renovascular diseae in middle-aged females = fibromuscular dysplasia (FA2019 pg. 592).

(2) Also notice the -classic- 'string-of-beads' appearance of the artery: EXAMPLE





Subcomments ...

submitted by seagull(1112),
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adwytpBssdlmeea/nBw_imys./igosdisoigF#eio:j/kpGiesSrdellmatiietrste/.itioap_hi/.c/mca:tkM

I leeveib stih si cuyaaltl estedmiadisn lBsoaesmtcy ude to eth dr"oaB seaBd ud"igndB as sene in teh irteup.c

seagull  However, given the stain and some of the features I now see that this is most likely Crypto. THey like similar. my bad +11  
mjmejora  oh what a catch! I also thought this was Blasto until you explained otherwise +  
drmohandes  Blasto = broad-based budding, the two 'circles' look equal in size. Crypto = narrow-based -unequal- budding. +6  
paperbackwriter  ^ I would disagree a little bit. "Broad based" and "narrow based" refer to how smushed the circles are. So narrow based is when the membrane bit they're sharing is small, and broad based is when they share a lot of membrane. So if just pinching off --> crypto, if they look stuck/have a flat membrane between them --> blasto +1  


submitted by vshummy(122),
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So eht sbet i loduc nidf was in Firts dAi 2109 gp 463 nuerd ciiebDat oaoticdsisK.e eTh ymrhalpgeiyce and remylipaaehk uecsa na oocmsit sieurisd os eth neiter odby estg lddteepe of ul.idsf Henec ywh tapr fo eth tteemtnar rfo DKA is VI duslif. uoY mihgt neve erly on ttha ecipe fo ianmirnotfo eloan to naersw tsih tsino,ueq that DKA is rtteade tiwh VI si.ufld

fulminant_life  I just dont understand how that is the cause of his altered state of consciousness. Why wouldnt altered affinity of oxygen from HbA1c be correct? A1C has a higher affinity for oxygen so wouldnt that be a better reason for him being unconscious? +6  
toupvote  HbA1c is more of a chronic process. It is a snapshot of three months. Also, people can have elevated A1c without much impact on their mental status. Other organs are affected sooner and to a greater degree than the brain. DKA is an acute issue. +3  
snafull  Can somebody please explain why 'Inability of neurons to perform glycolysis' is wrong? +3  
johnson  Probably because they're sustained on ketones. +2  
doodimoodi  @snafull glucose is very high in the blood, why would neurons not be able to use it? +1  
soph  @snafull maybe u are confusing bc DK tissues are unable to use the high glucose as it is unable to enter cells but I dont think thats the case in the neurons? +1  
drmomo  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909073/ states its primarily due to acidosis along wth hyperosmolarity. so most relevant answer here would be dehydration +  
drmohandes  I thought the high amount of glucose in the blood (osmotic pressure), sucks out the water from the cells. But you also pee out all that glucose and water goes with it. That's why you have to drink and pee a lot.. +6  
titanesxvi  Neurons are not dependent on insulin, so they are not affected by utilization of glucose (only GLUT4 receptors in the muscle and adipose tissue are insulin dependent) +19  
drpatinoire  @titanesxvi You really enlightened me! +  


submitted by m-ice(272),
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olrpotMioss si a nansaodrlpgti oaagln E)P2G( atht csat on het sacomht ot ropmteo ucmus ttpernoioc of eth tcmshao niilgn, tub oasl csat ni het eruuts to uneroegac onotcaicrnt, hhwci kesam ti lfesuu fro .oinaortb

usmile1  perfect except it is a PGE1 analog, not 2 +2  
krewfoo99  PGE2 will increase uterine tone (Pg. 270 FA 2018) +  
drmohandes  Misoprostol prevents NSAID-induced peptic ulcers. Side-effect: also gets rid of baby. +  


submitted by m-ice(272),
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Teh ttiepna nedes dieclma toeainntt itmieydm,lea chhwi ietlnsaiem nainbgoit a ruotc rdore, ro rgtnfriersan hr.e A ensur odes otn vaeh eth smea nnitirag nda uqniatfisalioc sa a ,haiscipny os it luodw eb anpaiprtripeo ot sak mhet to maiexen eht .natepit snAkig teh astloiph acialhpn anagi codlu be patapirenipro, and uowld atek moer ite.m ohTferere, eht ebts noitpo ngaom soteh eingv si ot kas eth panitet fi hse lwil wloal hiwt ehr daubnsh re.ptnse

sympathetikey  Garbage question. +44  
masonkingcobra  So two men is better than one apparently +23  
zoggybiscuits  GarBAGE! ? +1  
bigjimbo  gΓ‘rbΓ‘gΓ© +4  
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect? +10  
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39 +8  
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no. +12  
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh +20  
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask. +  
niboonsh  This question is a3othobillah +4  
sunshinesweetheart  this question is really not that garbage....actually easy points I was grateful for... yall are just clearly ignorant about Islam. educate yourselves, brethren, just as this exam is trying to get you to do. but yeah I agree there should be an option for female physician lol +5  
drmohandes  I think this NBME24 is a waste of $60. On one hand we have these types of questions, that have 0 connection to our week-month-year-long studying. On the other hand we have "Synaptobrevin" instead of SNARE, because f*ck coming up with good questions. +10  
myoclonictonicbionic  @sunshinesweetheart I actually have studied the religion tremendously and there a clear consensus among all Muslims that in the case of an emergency, it is completely allowed to have someone from the opposite gender examine you. I think this actually represents how ignorant the exam writers are of Islam. +6  
korahelqadam  All it takes is one NBME question concerning muslims for the Islamophobia to jump out I guess +  
sars  This is a very fair question. I agree with sunshinesweetheart above. That is all. +  
wrongcareer69  Garbage question +  


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hyW si ti ont rniavoa llleifco c?esll I htoutgh eht felema laango of orSitel and gdyLei is lrthaacoasunge/ celsl.

colonelred_  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +4  
brethren_md  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +3  
sympathetikey  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +4  
s1q3t3  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +7  
masonkingcobra  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen +2  
mcl  Wait, but did anyone mention that females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen??? +28  
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 +10  
bigjimbo  LOL +  
fallenistand  Females can get sertoli-leydig cell tumors, which are notorious for producing lots of androgen. +4  
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. +6  
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? +3  
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" +1  
youssefa  Hahahahaha ya'll just bored +4  
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 +4  
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 +1  
noplanb  Wait... I might actually never forget this now lol +1  
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!" +14  
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. +1  
alexxxx30  just made sure to add to my notes "Females can get sertoli leydig cell tumors, which are notorious for producing lots of androgens" +1  
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 +  


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utanolFcni hptraryadio ansmdeoa nac ucsea vleaeted iroapahdtyr honmreo ,(H)PT chhiw trluses ni aiaehmlycepcr nad .ehpaahtppoiohmys Hyearplaicemc si aiearrtchecdz yb teh nmirghy :pmoymsts seston (le,nra aryibl,i) soebn i(lunncigd oneb ipna ot sitsetio bsfoira iya)ccts, ngsroa adoailbm(n ia,pn n,)v/ norehts aurlio(y,p snoita,ocpit)n dna rthpsiaiycc seenorvot (fmro rdopisnees ot ca)om.

drmohandes  Great explanation, thanks. Does anyone know why this patient is anemic though? Is there some link between hyperparathyroidism and anemia I am missing? +  
drmohandes  *Patient erythryocytes = 3million/mm3 (normal 3.5 - 5.5) +  
melchior  From googling, it looks like it just happens. One author says that high concentrations of parathyroid hormone downregulate erythropoietin receptors. Regardless, it corrects after parathyroidectomy, showing that parathyroid hormone likely causes it, somehow. https://www.ncbi.nlm.nih.gov/pubmed/10790758 https://academic.oup.com/jcem/article/97/5/1420/2536309 +  


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tnFaouciln yhtairaprdo nmsedoaa nac aeusc teldeeav rohpatiaryd hmeonor ),PH(T hwcih sltrsue ni ehcarieymcalp dna hpyehhpo.sopmaita pacmilarHeeyc is atzeciacdhrer yb teh gymhinr :ypssmmot sensot e,nalr( ,ibr)layi beons dnil(ciung eonb pian to soesttii raisfbo tai)sycc, nsroag lai(oamdnb i,anp )vn/, othnser uiy,plora( nio,)itcoapstn and hptiryaicsc erstonevo mrof( eidsspneor to c.am)o

drmohandes  Great explanation, thanks. Does anyone know why this patient is anemic though? Is there some link between hyperparathyroidism and anemia I am missing? +  
drmohandes  *Patient erythryocytes = 3million/mm3 (normal 3.5 - 5.5) +  
melchior  From googling, it looks like it just happens. One author says that high concentrations of parathyroid hormone downregulate erythropoietin receptors. Regardless, it corrects after parathyroidectomy, showing that parathyroid hormone likely causes it, somehow. https://www.ncbi.nlm.nih.gov/pubmed/10790758 https://academic.oup.com/jcem/article/97/5/1420/2536309 +  


submitted by seagull(1112),
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fI yuo tdon' oknw atwh uoarcDilm sode elik nya almonr nuh.am eTh ucosf no tawh iniraps 'ndoste ,od ynmela its' todsn'e ctffea PT etim and tsmo pisll dot'n aiecrnse ttogclni (esllyiecpa htwi aipins.r) ihsT is owh I logci to hte rtihg ne.asrw

usmleuser007  If that's then thinking, then how would you differentiate between PT & PTT? +11  
ls3076  Why isn't "Decreased platelet count" correct? Aspirin does not decrease the platelet count, only inactivates platelets. +4  
drmohandes  Because dicumarol does not decrease platelet count either. +  
krewfoo99  @usmleuser007 Because the answer choice says decrease in PTT. If you take a heparin like drug then the PTT will increase. Drugs wont increase PTT (that would be procoagulant) +3  
pg32  I think usmleuser007 and is3076 were working form the perspective of not knowing what dicumerol was. If you were unsure what dicumarol was, there really wasn't a way to get this correct, contrary to @seagull's comment. You can't really rule out any of these as possible options because aspirin doesn't do any of them. +2  
snripper  yeah, it wouldn't work. We'll need to know with Dicumarol is. +3  
jackie_chan  Not true, the logic works. You gotta know what aspirin does at least, it interferes with COX1 irreversibly and inhibits platelet aggregation (kinda like an induced Glanzzman), all it does. PT, aPTT are functions of the coagulation cascade and the test itself is not an assessment of platelet function. Bleeding time/clotting time is an assessment of platelet function. A- decreased plasma fibrinogen concentration- not impacted B- decreased aPTT/partial- DECREASED, indicates you are hypercoaguable, not the case C- decreased platelet count- aspirin does not destroy platelets D- normal clotting time- no we established aspirin impacts clotting/bleeding time by preventing aggregation E- prolonged PT- answer, aspirin does not impact the coagulation factor cascades in the test +1  
teepot123  di'coumarin'ol +  


submitted by armymed88(48),
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eeympmhas lsaed to O2C ipagnptr glndaei ot eenisarc 2CapO ni eht l,obdo ichwh isegv oyu a rostyerapir cisdaiso r poPre eranl nenomipscato ilwl rcieasen bcdair ebras adn cdeeaesr cr-eoeintx vgiign yuo drenicase icbbra ni teh boldo

meningitis  Increased blood HCO3 could have easily been interpreted as increased blood pH aswell. FOllowing your explanation, since the pt had acidosis, the increased HCO3 will just make it a normal pH. Another way to think of the question is: if there is decreased exhalation due to COPD --> increased CO2 --> increased CO2 transported in blood by entering the RBC's with Carbonic Anhydrase and HCO3 is released into blood stream. So increased CO2 -> increased HCO3 seeing as this type of CO2 transport is 70% of total CO2 content in blood. +19  
drmohandes  I thought you could never fully compensate, so your pH will never normalize. Primary problem = respiratory acidosis β†’ pH low. Compensatory metabolic alkalosis will increase blood HCO3-, but not enough to normalize pH, it will just be 'less' low, but still an acidosis. +3  
mtkilimanjaro  I also think decreased blood PCO2 and increased blood pH are very similar (less CO2 in the blood means less acidic, pH could go up) therefore I ruled both of them out just from that +