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Comments ...

 +3  (nbme21#48)

I get that this answer choice is the most amicable answer.

But honestly the way they asked the question "it is most appropriate for the physician to address the issue of a feeding tube in which of the following manners"

My reasoning was: well...before the family can even begin to argue what do do don't you have to propose a medical treatment/management strategy? which is why I went with "recommend a tube..."

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?
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."
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.




Subcomments ...

submitted by yotsubato(282),

Why is his Libido normal? It's totally expected that he may have reduced libido after his wife died 2 years ago from some horrible prolonged illness.

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(85),

from AAFP ED of mixed organic and psychogenic origin is common. Psychogenic causes are more likely when the patient has normal erections with masturbation or when nocturnal penile tumescence is normal.

yotsubato  Couldnt a psychogenic cause reduce libido? +  
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 +6  
home_run_ball  whoops meant to comment on the other comment +  


submitted by haliburton(85),

from AAFP ED of mixed organic and psychogenic origin is common. Psychogenic causes are more likely when the patient has normal erections with masturbation or when nocturnal penile tumescence is normal.

yotsubato  Couldnt a psychogenic cause reduce libido? +  
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 +6  
home_run_ball  whoops meant to comment on the other comment +  


submitted by step420(18),

I have a question: Since CO = SV * HR, and in pregnancy, women have an increased basal HR, why can't the answer be Pulse?

home_run_ball  I don't think HR would explain the grade 2/6 murmur, but SV would +1  


I get that this answer choice is the most amicable answer.

But honestly the way they asked the question "it is most appropriate for the physician to address the issue of a feeding tube in which of the following manners"

My reasoning was: well...before the family can even begin to argue what do do don't you have to propose a medical treatment/management strategy? which is why I went with "recommend a tube..."

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? +6  
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." +  
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  


submitted by ark110(1),

But what is the difference between option A and option C (132; 4.9; 90; 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. +  
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(69),

Propanolol is a non-selective Beta blocker. So your HR will decrease (B1), which will cause a compensatory increase in TPR.

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. +11  
amarousis  so why tf do we give beta blockers for hypertension -.- +2  
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 +