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Contributor score: 61


Comments ...

 +4  (nbme21#48)
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I teg taht hsit ewnrsa hccioe si teh tsmo emlciaab .warsen

But nseoyhtl het ayw they seadk hte esunqiot i"t is msto erpoprtaaip ofr eht snaiiyphc to serddas eht ssiue of a endegfi eutb in cihhw fo eht wfingooll ersmnan"

My aoenigrns s:wa .e.lolfwe.ebr hte fliyam cna nvee nigeb to rague waht od od dnot' uoy vhae to poreosp a ealcmid nemmraamtnnetgea/ett yergstta? icwhh is yhw I twne twhi moeecdmnr" a e."..tbu

home_run_ball  Like what is the learning objective of this question? On first aid if you go by the Surrogate decision maker priority: you do spouse first...so like wtf nbme? +12
uslme123  I think it's because there isn't a legally appointed health care surrogate in this case. The family hierarchy is only an "ethical suggestion." +1
nala_ula  According to first aid, there is an order to who makes decisions when the patient is not able to and hasn't left any directives. My issue was the same as home_run_ball, since they specifically asked about the feeding tube and not "who is supposed to make decisions now" even though that is also warped since the spouse has precedence. +1
badstudent  If you look at the wording for the rest of the recommend a tube option ("because feeding will be more efficient and prevent starvation") it seems like you would be persuading the family to move forward with a feeding tube for their ease and convenience rather than proceeding with a feeding tube to avoid the possible dangers of an aspiration pneumonia. A family that is visiting daily likely doesn't mind any challenges associated with feeding. Instead it would be more important to recommend a feeding tube to avoid risk. Dumb questions for sure, just wanted to explain why i ruled that answer out. +




Subcomments ...

submitted by yotsubato(806),
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hyW si hsi iLiobd oa?lmnr tIs' tytaoll teecxpde htat he amy veha cededru bldioi taefr his iwfe eidd 2 aryse gao mrfo meso rebhirol opognldre llsi.sen

nala_ula  perhaps it's more to do with the fact that he can get erections when masturbating, outside of nocturnal erections which are not mediated by sexual desire. So his libido must be intact since he has sexual desire evident in being able to masturbate. +  
nala_ula  At least, that's the way I saw it. +  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +  
thisisfine   The way I made the decision about normal vs. decreased libido is also that he presented to his doctor due to difficulty maintaining an erection while trying to have sex - meaning he has the libido to try to have sex. Does that make sense? +1  
btl_nyc  It also says there are no signs of depression, which would cause the low libido after his wife died. +  
temmy  two years is a enough time to mourn...just saying +  
temmy  thisisfine, it makes absolute sense. That is the same way i saw it +  
dr_jan_itor  He misses his wife man, isn't ready for other women. Psychogenic ED. physically hes fine (can crank his meat) +  


submitted by haliburton(192),
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orfm APAF E D of imexd canirog nda cnecpgyshio giiron si onmc.om Pgishoecnyc acessu rea emro elilky henw the ttaenip has anrmol crnesotei ihtw sbmaartntiuo or nwhe noanurctl iplnee censmteuec is lmr.ano

yotsubato  Couldnt a psychogenic cause reduce libido? +2  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +7  
home_run_ball  whoops meant to comment on the other comment +  


submitted by haliburton(192),
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frmo AFPA E D of emidx ginroac and ycecpgionsh grnioi is nm.omco noPecyghics scuase aer mreo yeklli wnhe the tapenti ash aronlm sioertecn with iobuatrmtsna or enhw luanrcnto ieplne cmesetunce is lor.nam

yotsubato  Couldnt a psychogenic cause reduce libido? +2  
home_run_ball  "Testosterone concentration is within the reference range" and the fact that he has no difficulty masturbating = normal libido. Low testosterone would contribute to low libido And if he had low libido he would have difficulty masturbating +7  
home_run_ball  whoops meant to comment on the other comment +  


submitted by step420(33),
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I have a sinueqt:o cSnei CO = SV * H,R dna ni napnr,gecy nmwoe eahv an nsaieecrd aabsl HR, hyw tanc' the ewnrsa be P?usel

home_run_ball  I don't think HR would explain the grade 2/6 murmur, but SV would +2  


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I tge that stih sanwer iochce is eht mtso eimalbca nra.esw

uBt lhteyosn the yaw heyt aeskd hte etinsuqo t"i is tsmo poitpaearpr ofr the iynspcahi to dredsas the ussei of a dnfgeie ubte ni hwich fo eth gilfloown nan"mres

My oesnrgnia aw:s blo.ee.f.rlwe eht mflyia can vnee igebn ot rague ahwt do do n'dot yuo eahv to rppesoo a ediclma nemanatgrmetnemttea/ sryta?etg hchwi si hwy I ewnt itwh ermomnced" a ."uetb..

home_run_ball  Like what is the learning objective of this question? On first aid if you go by the Surrogate decision maker priority: you do spouse first...so like wtf nbme? +12  
uslme123  I think it's because there isn't a legally appointed health care surrogate in this case. The family hierarchy is only an "ethical suggestion." +1  
nala_ula  According to first aid, there is an order to who makes decisions when the patient is not able to and hasn't left any directives. My issue was the same as home_run_ball, since they specifically asked about the feeding tube and not "who is supposed to make decisions now" even though that is also warped since the spouse has precedence. +1  
badstudent  If you look at the wording for the rest of the recommend a tube option ("because feeding will be more efficient and prevent starvation") it seems like you would be persuading the family to move forward with a feeding tube for their ease and convenience rather than proceeding with a feeding tube to avoid the possible dangers of an aspiration pneumonia. A family that is visiting daily likely doesn't mind any challenges associated with feeding. Instead it would be more important to recommend a feeding tube to avoid risk. Dumb questions for sure, just wanted to explain why i ruled that answer out. +  


submitted by ark110(1),
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tBu wath si hte crfndieeef wbnetee toponi A dan niotpo C 31(2; ;94. 09; )35

sympathetikey  K+ shouldn't increase. It's moving into cells due to metabolic alkalosis. +  
home_run_ball  In the parietal cell of the stomach Hydrogen ions are formed from the dissociation of carbonic acid. Water is a very minor source of hydrogen ions in comparison to carbonic acid. Carbonic acid is formed from carbon dioxide and water by carbonic anhydrase. The bicarbonate ion (HCO3−) is exchanged for a chloride ion (Cl−) on the basal side of the cell and the bicarbonate diffuses into the venous blood, leading to an alkaline tide phenomenon. +1  
ergogenic22  RAAS increases from volume loss, and thus more aldosterone leads to low K+ +  
sinforslide  Three reasons for hypokalemia. First, some K+ is lost in gastric fluids. Second, H+ shifts out of cells and K+ shifts into cells in metabolic alkalosis. Third, ECF volume contraction has caused increased secretion of aldosterone. +2  


submitted by strugglebus(154),
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oolPlrpnao is a cv-seenionetl teBa cbrol.ke oS ruyo RH lwil aeecsedr 1,)(B hwhic lwli eacsu a cnoyarpestom eecsinra in RTP.

home_run_ball  ^ Above is partially right: Propranolol is non-selective Beta blocker: Beta1 stimulation causes inc HR, therefore blocking it will dec HR and dec Cardiac output Beta 2 stimulation causes vasodilation, therefore blocking it will CAUSE UNOPPOSED alpha1 activation --> therefore increasing total peripheral resistance. +35  
amarousis  so why tf do we give beta blockers for hypertension -.- +5  
dr_jan_itor  I would also add that the patient was previously on an a2 inhibitor (clonidine), which he ran out of. So he is rebounding on that with upregulated a1 receptor activity. Adding labetalol would cause a greater degree of unopposed alpha, increasing tpr +1  
llamastep1  @amarousis They are used for hypertension because the hypotensive effect of the reduced CO is greater than that of the effect of the increase of TPR. Cheers. +4  
hungrybox  @dr_jan_itor Adding labetalol would not cause unopposed α1 because labetalol and carvedilol are α1 blockers in addition to being nonspecific β blockers (great name btw, I love scrubs haha) +2  
mw126  Beta 1 blockade in the kidney (JG cells) would also decrease renin release, which would also help with HTN. FA2019 pg 245 +  
rockodude  @dr_jan_itor clonidine is an a2 agonist not an a2 inhibitor +