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Welcome to forerofore’s page.
Contributor score: 57

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 +3  (nbme21#35)
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htsi itenatp eretssnp twhi mpoyocirhch m,eaian it otcann be ahsgoipemnamye caeebus ti nsoetd uacse mna,eai nctnoa eb 21B ubecaes ti udwlo be oegciballta,sm tanocn be tnimaiv D ebuscae ist ton eerladt to hcypmrihooc aei,nam nda iznc is astcoiseda hitw ionr cenyidecfi iaame,n btu as a ceei.ifncdy Aols, aeld ionpogsni tiisihbn toarcrseafe,ehl ti slkoo ilke an iorn ncdieeiyfc emiaan btu sneci teerhs on ethro alclogi otiopn ti has ot eb teh rwanse ereh


Subcomments ...

submitted by rockediny(10),
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txDeor si het octcrer reanws .hree rmoF the hseccoi ve,gni tdroxe si hte latse klyeil ot aseuc tnasoncipiot ensci ist nami imsmhaecn of coaint si DNMA iatsnmnoag w/oesm piiood tcyitvia -- ti nca acseu oocpaiistnnt tbu teh toreh cioehcs rea UCMH OMRE yllkei ot. sA orf neidhrmpeahnidy = it is ton aaitprroepp fro edlrley itnetpas and it i’nst na iseuas.titvn

forerofore  diphenhydramine and other Gen 1 antihistamines are good choices for chronic cough in allergy and patients with posterior draining and post viral chronic cough (careful with the elderly). That being said, apparently it also causes constipation, so dextro is still the correct answer. +2  
passplease  Could it also be that you would not prescribe diphenyhyrdramine because they are part of the beers criteria and should be avoided in the elderly? +3  

submitted by iviax94(7),
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Three vaeh eenb a oulcpe fo osnesqitu boaut iths opict no het nreew saxem. Iv’e eebn negwranis by nutgieaq ibildo ot otenrettseos vsleel nad ctanrnlou ieoscntre to hthlea fo lctueasvura caretosirolse(hs or sI shti o?cerrtc

liverdietrying  When you’re thinking of libido, don’t just equate it to testosterone -- make sure you’re always considering depression! Depression following stroke is common, especially with residual physical disability, so this would decrease his libido. Nocturnal erections equate to “does it actually work?” not just the vasculature but the neural input as well. For example, during prostatectomy damage to the pelvic plexus (nerves) can lead to impotence. There’s nothing to suggest that he has vascular or neurologic erectile dysfunction here, which is why his nocturnal erections are intact. +26  
_pusheen_  @liverdietrying Was it premature to assume he has trouble with erections because of neural damage from the stroke? I put low libido, low nocturnal erections. Is it because the stroke resulted in hemiparesis and not autonomic dysfunction or something like that? +5  
liverdietrying  @pusheen Correct, you won’t classically get impotence after a hemiplegic stroke. His inability to achieve an erection is much more likely to be 2/2 psychosocial effects than organic disease. If this vignette instead said that this had gotten a prostatectomy with resulting damage to the pelvic nerves that allow for erection, then it’d be a more safe choice to put no nocturnal erections. +4  
fast44  Is there a video or somewhere that explains these sexual dysfunctions? This seems to be a topic that keeps repeating on the new exams. +2  
forerofore  well, i though that because he had a stroke he would be likely to have atherosclerosis, which would keep libido high and reduce nocturnal erections, i kinda ignored the whole "he´s depressed" part of the vignette despite understanding the mechanism well. but from a clinical depression point of view, if his arteries are intact, and he is depressed, then libido would be low, and erections present at night. +4  
pg32  I can't remember exactly but I swear the question on NBME 21 the guy's wife had died as well...? Or they had gotten divorced? Either way, he had some psychological baggage as well, but his libido was still normal, and the explanation was that his testosterone would be fine regardless of his depressed mood. So I went with that logic here and missed this question. I don't understand how I am supposed to gauge someone's libido based on vague hints at their mood, especially when in one exam mood does not decrease libido and in the other it does. +  
drzed  @pg32 bro spoilers +2  

submitted by medstudied(1),
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nCa meeonso sleeap nleaxpi why teh nawser ot hsti si inuyjr to eth orpriseot drco earthr nhta eth dalrai n?eevr

pipter  because raising the arm above the shoulder suggests abduction which would mean the axillary nerve is also involved. the lesion would be more proximal. +7  
kchakhabar  I thought "up to the shoulder" is done by deltoid muscle (aka axillary nerve) and above is done by trapezius. +4  
forerofore  as far as i can find, abduction ranges of motion, per first aid are: 0-15° = supraspinatus 15-90° = Deltoid 90° = trapezius 100° (over the head) = serratus anterior in this question, they are directly telling you its not the serratus (long thoracic), because no option compromises it. Also, trapezius is innervated by cranial nerve XI, which is not a part of the brachial plexus, so, even though its worded weirdly, you can assume they are talking about deltoid disfunction. so deltoid disfunction (axillary) + radial disfunction = posterior cord +3  

submitted by pppro(23),
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Yaiisnre irvshte in clod retuaspermet dan can eb antdoibe omrf ropo dtinaseat m.ilk ckh(eC sykhcet )estkch

forerofore  growth in cold temperatures seems to be the method of isolation of yersinia enterocolitica +  

submitted by lamhtu(113),
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It aapesrp ttah hthaglou TsRIN rea rledaospyhhpot yb eyhmndiit nkeis,a steaincers is lyalctua ued ot tminauots in het ltacua sveerer resainstctpra hrtear ntha myndthiei enskia

forerofore  mutations in thymine kinase are more frequent in herpes drugs +3  
mtfp  NRTI need to be phosphorylated by HOST CELL thymidine kinase, mutation in viral kinase has no role in NRTI resistance +10  

submitted by pppro(23),
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nePtiat ash PH.B Gvie laahp eno ontaiantsg ot euercd tsoohm lumces oiaocttcnnr nda liveere cdyltififu runii.angt

d_holles  lol i thought it was some kind of urinary retention problem and put H. +15  
sbryant6  How is H wrong? Oxybutinin or tolterodine treat urinary incontinence by blocking M3 muscarinic acetylcholine receptors --> urinary retention. We're just supposed to assume they are talking about BPH here because he is old? +  
jaxx  I agree. I picked "H" for that same logic. Does anyone know where we should have come to the conclusion that this was BPH? +  
forerofore  they are telling you he's having "difficulty urinating", one of the clinical criteria for BPH is reduced urinary flow rate. this is not incontinence because they are not telling you he leaks at all, just that he pees "a lot" +12  
drzed  Even if he was urinating too much, anticholinergics are contraindicated in the elderly (Beers criteria) +3  
pathogen7  @drzed tI mean techinically alpha-1 blockers are on the Criteria too ... +1  

submitted by seagull(1404),
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ignxaEmni aetnipt omrf a goiortuls sileipm Bkrneos sBia ihwhc louwd kwse eht utipnaolop anem fo usemr raue ioretgnn aywa morf eth ruet aeraucct nae.m h,nTe iezrlae opscnieri is nteepdnde on tiaatiltcss w"Preo" hihwc is anrsedcei sdbae on het iesz of teh oaoipnuplt fo hte .uydts eercdsi(na piesnrcio = isnercdae taiacissttl wep)r.o eoeTfrre,h na cereaisn in luotnpaiop fo a ibsade pgrou iwht aeld ot caicyruanc wiht ghih

forerofore  to add up, the urologist himself doesn't add or remove accuracy (since this is a blood test), what decreases the accuracy is the fact that in order to be sent to a urologist you probably are sick in the first place (selection bias), so your urea nitrogen is likely to be altered. +21  
sharpscontainer  I thought of precision as more of a function of variance. Variance will decrease with a greater sample size. Had a hard time because I was thinking about those 4 darn targets (wouldn't 500 darts look more spread out than 10? but no, the variance will be better) that have been in my textbooks since 7th grade and for the first time I was asked a question about this concept only to discover that I didn't have it down as well as I assumed. +1  
peridot  @sharpscontainer I feel you, I thought the exact same thing. Looked into it a bit and I think it has something to do with the way standard error or standard deviation or something like that is calculated, but I'm still confused and too tired to dig further. Also, wanted to mention that this NBME has a similar question but instead it's about the 95% confidence interval - maybe that'll help you understand the precision thing better since the 95% confidence interval narrows with a larger sample size? So it's kinda tied to precision? +  

submitted by neonem(550),
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jaoMr krsi facotr for oarcit oedsnistci is netper,yosnhi dna in ihst scae hgitm eb deu to necoaic u,es hhicw uascse daekrm rypnnheeitso. snciieoDsst ecuas a trae in the icnatu inamti -- loobd nac fwol bdwasacrk niot hte cpmriearuid dna seuac tneamdoa.p shiT aftisemns sa arlccesk in hte lgun ued ot oorp ftel trucivlearn itofunnc iidciaoslglnl(fti/ rplembo deu ot smscr).opieon

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9  
temmy  please why is there where a diastolic mumur? +1  
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8  
garibay92  Does anyone know why is this patient's tepmerature elevated? +1  
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1  
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +  
almondbreeze  he's only 28 - another clue for marfan? +  
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2  
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1  
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +1