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Contributor score: 20

Comments ...

 +1  (nbme23#35)

I get this is a fluffy question and acknowledging the patient's reasons for missing insulin injections is the cuddliest, but I feel like this answer tows the line a bit. You don't want to say that missing doses is ok, but you also don't want to be mean to patient either. I thought this answer (A) was condoning her missing the injections, so I picked (C). In retrospect, I guess acknowledge means talk about/focus the conversation around.

dentist  I would say: "I understand why you are missing injections, but you're going to have a BAD TIME IF YOU KEEP MISSING INJECTIONS"
alexxxx30  @dentist, I was searching for that answer as well, but it wasn't there so I picked C ahahaha

 +8  (nbme22#3)

This question has a lot of answer options, and you arrive at Nephrolithiasis by throwing out all the other options by what is missing.

A, B - Cortical Necrosis and Papillary Necrosis almost always occur in the setting of ischemia. Previously healthy 28 year old man has no evidence of significantly decreased renal perfusion.

C - Acute Tubular Necrosis is what you should think of with Salicylate (NSAID) toxicity. There are many other nephrotoxic drugs that cause ATN, but think of ATN as drug induced kidney damage.

D - Cystitis - Flank pain is related to kidney injury, not bladder damage. Cystitis could be possible in ascending UTI, but the patient has no fever and is male (much less common in males).

E - Glomerulonephritis - This gets into nephrotic/nephritic syndromes. The stem mentions that he has blood in the urine which may lead you down the nephritic pathway, but he does not have any of the other associated symptoms.

F - Hypernephroma - Another word for Renal Cell Carcinoma. No weight loss or other cancer related symptoms (fatigue etc.)

G - Interstitial Nephritis - This is often a drug induced IMMUNE mediated nephrotoxicity. This is a type IV hypersensitivity reaction that occurs weeks to months after the start of medication (like NSAIDs). ATN is more associated with drug overdose while Interstitial is more associated with immune reaction. Intersitial Nephritis will have WBC casts in urine.

I - Pyelonephritis - Caused by ascending UTI but no fever is present.

This leaves Nephrolithiasis (H) as the correct answer. 85% of Nephrolithiasis is associated with hypoactive bowel sounds. The pain for nephrolithiasis can relapse and remit, and occasionally the pain can travel from the kidney (flank pain) to the scrotum as the stone moves through the ureter.

whoissaad  Great explanation. Always found it hard to differentiate between ATN and AIN due to NSAID use. This made it clear. Thanks!
hyperfukus  yasss
dubywow  "occasionally writhes in pain" -- as a guy who has had a kidney stone, writhing in pain definitely hits the mark. Picture yourself knees on the ground, face on the couch, screaming incoherently while the paramedics are there because you can't control your own body movement and don't know if you're dying or whatnot from the canonball sized hole that (may or may not be) in your flank. Then imagine one of the paramedics is your premed study buddy. Never forget writhing and nephrolithiasis and premed study buddies. You will forever get this question correct in the future.
bharatpillai  i swear to god ive done a similar question on the usmlerx qb and they answer was renal papillary necrosis. which is why i got it wrong :(
targetmle  i also remember that uw ques which got me this ques wrong. i think in that ques,patient sibling or he himself had sickle cell

 +4  (nbme22#19)

This question gets at whether or not you can recognize Trousseau's Sign or Chvostek's Sign in kind of an unusual presentation. Basically you get muscle twitches in the setting of Hypocalcemia. Hypoxemia further exacerbates the sign and can cause twitches randomly throughout the body.

Chvostek's Sign is tapping on the facial nerve of the face that illicits a facial muscle spasm.

Trousseau's Sign is when you put a blood pressure cuff on a patient. This causes cells in the arm to not recieve blood -> No O2 -> No oxidative phosphorylation -> decrease in ATP available -> Na+/K+ pump fails without ATP -> Increased intracellular Na+ -> Increased Ca+ because of increased Na+/Ca2+ exchanger -> decreased SERUM Ca2+ -> Flexion of hand.

Trousseau's Sign is more sensitive for Hypocalcemia, but both are diagnostic. Other tips in this question - Tingling around the mouth, hands, and feet can be another sign of Hypocalcemia. Both generalized tonic-clonic or focal motor seizures can occur with hypocalcemia.

waterloo  Something that could help. Gabapentin is a narrow spectrum anti-epileptic drug used to treat seizures. It blocks voltage gated Calcium channels. It also treats neuropathic pain (which this vignette hints at both). My thinking for this question: the patient is having seizures so must be sodium abnormality. But then they mention the pins and needles and involuntary contractions, and this being the first seizure, it sounded less like a sodium issue and more so Calcium. I think what hopsalong said makes a lot of sense. I think there is a pharm angle this question could have taken as well.

Subcomments ...

submitted by jrod77(21),

I think they might be describing angina...not sure. TXA2 is responsible for platelet aggregation,so it may be contributing to thrombosis, thus ischemia to the cardiac tissue.

sympathetikey  Agreed. I'm pissed though because PGE2 mediates pain, which is why I picked it. +17  
he.sanchez14  If im not mistaken, the question describes unstable angina. Unstable angina is due to thrombosis with incomplete occlusion. So, yes TXA2 is responsible for the thrombus that is causing the symptoms in this patient. I'm also pissed because I also went straight for the PGE2 +2  
vik  hahah, seems like all in same boat like me +  
yb_26  thromboxane A2 is also vasoconstrictor, so my thoughts were about vasospastic angina +1  
shriya goyal  same I went for pgE2 ... I M PISSED +1  
shriya goyal  same I went for pgE2 ... I M PISSED +  
youssefa  Went for PGE2 ... shit +  
need_answers  I went for leukotriene B4, what the hell was I doing....SHIT +3  
hopsalong  I picked Leukotrine B4 thinking that the neutrophil infiltration was the source of the pain, seems wrong lol. +  
bballhandler11  Sometimes it helps me to think of it in a general, non med school textbook kind of way. When answering, I narrowed it down to PGE2 and TXA2 as well. Then I asked myself, if someone is experiencing chest pain, would I recommend Aspirin or Advil? That's helped on a few over the counter pharm questions. +4  
ususmle  same here I M PISSED PGE2 +1  
krewfoo99  Maybe PGE2 isint the answer because it mediates pain and fever during episodes of acute inflammation? Thus making TXA2 more likely. +1  
djtallahassee  ditto on the looked at it for 2 seconds and went PGE2 +  

submitted by sugaplum(157),

FA 2019 pg 612 Endocervix-simple columnar epithelium

hopsalong  I use barrett's esophagus to remember these questions. Remember barrett's esophagus is squamous to columnar metaplasia -> this happens because of increased acid in the esophagus. What this means is that columnar cells are better for dealing with acid/internal fluids, and are a better cell type. Squamous is a better cell type for dealing with outside irritants. This means the vagina will be lined with squamous cells normally, and the cervical canal will be lined with columnar epithelium. +7  

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