Welcome to jesusiskingโs page.
Contributor score: 31
Comments ...
drdoom
need more cowboys in these here parts ..
+3
jesusisking
Also sacroiliac joints eroded and sclerosed
+2
charcot_bouchard
Actually yes. They behave aggressive in response to aggression like police apprehension. Best thing to do with them is politely taking them to a quiet room, dimly lit. Gentle handling of a strong feline.
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qfever
this comment makes my mood better
+1
charcot_bouchard
You wouldn't expect baseline low BP at that case. Also other features like fever suggest alt dx
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Subcomments ...
jesusisking
Also sacroiliac joints eroded and sclerosed
+2
jesusisking
Why wouldn't it be platelet transfusion 1st?
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deathbystep1
well the question said "his gums started bleeding when he brushed his teeth". So wouldn't that be considered active bleeding? I was aware about the aafp guidelines as there was a similar question in Uworld as well. The only reason i chose platelet transfusion was because he was "actively" bleeding from the gums. Otherwise it was clear that he had pancytopenia and you need to do a bone marrow biopsy.
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zalzale96
Isn't bone marrow aspiration considered an invasive procedure and thus we should transfuse since his platelets level is below 50k?
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osler_weber_rendu
Acc to UW, in children transfuse ivig, steroids, anti D only if child has more than mucocutaneous bleeds. In adults it is done if the count is below 30k irrespective.
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jesusisking
Why wouldn't it be platelet transfusion 1st?
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deathbystep1
well the question said "his gums started bleeding when he brushed his teeth". So wouldn't that be considered active bleeding? I was aware about the aafp guidelines as there was a similar question in Uworld as well. The only reason i chose platelet transfusion was because he was "actively" bleeding from the gums. Otherwise it was clear that he had pancytopenia and you need to do a bone marrow biopsy.
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zalzale96
Isn't bone marrow aspiration considered an invasive procedure and thus we should transfuse since his platelets level is below 50k?
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osler_weber_rendu
Acc to UW, in children transfuse ivig, steroids, anti D only if child has more than mucocutaneous bleeds. In adults it is done if the count is below 30k irrespective.
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_yeetmasterflex
Could the pneumothorax also cause less ventilation due to decreased lung surface, retaining more CO2 causing respiratory acidosis? That's how I got to the answer at least.
+8
duat98
I think pneumothorax would increase RR because you're probably hypoxic. Also I'm sure when you have a lung collapse on you you'd be scared and that would trigger your sympathetic so your RR will go up either way.
+4
bullshitusmle
there is no bilateral lung opacities as you would see in ARDS
+5
jesusisking
Was thinking some sort of infection b/c of the atelectasis so picked empyema but this makes sense!
+1
djeffs1
does it need to be ARDS to cause "diffuse alveolar damage"?
+1
makingstrides
Not only that, does having a collapsed lung affect the alveoli?
+1
yb_26
@at0xibolic, I think you won this competition on finding better picture lol thanks
+6
focus
Ugh I was thrown off by "disruption of vascular basement membranes" since it seemed similar to the correct answer but I can see how "separation" would be a normal, expected response of the body that is needed vs. "disruption" would be traumatic and abnormal... please correct me if I am wrong!
+2
blah
@focus reasoning sounds right. I nearly picked that but the other choice sounded better. Just semantics.
+4
aakb
um just to clarify I don't think the differentiating factor is the wording of separation vs disruption.
but rather that the correct answer is separation of ENDOTHELIAL junctions meaning that the spaces between the endothelial cells get wider.
vs the answer youre thinking of says the disruption of the vascular BASEMENT MEMBRANE (which is under the endothelial cells) gets disrupted. so meaning something literally broken through the blood vessel and made a cut in the layer beneath the endothelial cells that line the blood vessel
Dr. Sattar from pathoma usually draws a basement membrane and a layer of endothelial cells sitting on top
+6
drzed
Vasodilation of the skin is under sympathetic control as well -- beta-2 receptors when stimulated cause vasodilation (via increase of cAMP in vascular smooth muscle). The key is recognizing that stimulation of a GANGLION of the pns will lead to release of NOREPINEPHRINE, which preferentially stimulates alpha-1 receptors. Those receptors will cause vasoconstriction.
If the question asked what happens when you stimulate the adrenal medulla, the answer would be (potentially) vasodilation. This is because the adrenal medulla releases EPINEPHRINE which preferentially stimulates beta-1/2 receptors.
+12
jesusisking
@drzed Awesome explanation except I think sympathetic response induces vasoconstriction in the skin though vasodilation in the muscles!
+1
usmile1
@jesusisking yes you are correct!
ฮฑ1: vasoconstriction in skin and intestine ;
ฮฒ2: vasodilation in skeletal muscle (transmitter: only epinephrine!)
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an1
sympathetic response is going to fight or flight. you'll be sweating, you want the sweat to dissipate so your body temperature doesn't shoot up. To reduce temperature, there is vasoDILATION at the skin and vasoCONSTRICTION of the splanchnic vessels. Confirm with UW QID 19088 (image)
+1
an1
actually no don't lol, check out the image it'll make sense. @drzed is correct, HR was a better option here though
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an1
re-read the question here. might be taking a big leap but maybe the electrical stimulation is a give away. Yeah stellate is SNS leading to HR increase, sweating, increased blood pressure but if it's electrical stimulation, why would the skin vasodilator? it vasodilator to get rid of excess heat, which shouldn't be present with a minor electrical stimulation
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jesusisking
You wouldn't use Standard error with Confidence Interval? (pg. 262 FA 2019)
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miriamp3
@haozhier if you are deciding to think that he had a ATN because of the 4 weeks.. then he should be by now in the recovery phase(polyuria, Bun/cr fall) But he is with HF and his urine output has progressively decrease. So AKI prerenal HF Bun/cr >20. the only one is D. Don't get confused with the rest of the information.
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jesusisking
I thought the same thing so chose C as well!
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charcot_bouchard
Exactly. If she was cracking the egg on Baby's head u stop her lol (i am cracking up on my own jokes)
+6
jesusisking
I feel it but dang, she lowkey drizzlin salmonella all over that baby
+2
thrawn
But what if the next step of this tradition is feeding the raw egg to the child. It happens in some cultures... I think telling her to continue is wrong - catious indifference seems prudent
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kavarthapuanusha
I knew this would be the answer , but i dint put this coz i am not crazy !!!
Tbh no one asked the physician if she should continue or not ! Thats like an unnecessary addition , may be " i understand your concern , but why dont we try to change the formula"
Would have made more sense!!
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catch-22
Start at the pontomedullary junction and count from superior to inferiorly (or medially to laterally): VI, VII, VIII, IX.
+3
yotsubato
I looked at the left side (cause the nerves arent frazzled up). Saw 7 and 8 come out together nicely. Then picked the right sided version of 8
+15
lolmedlol
why is it not H or I on the right side; the stem says he has hearing loss on the right side, so the lesion should be ipsilateral no?
+4
catch-22
You're looking at the ventral aspect of the brainstem.
+11
catch-22
^Also, you know it's the ventral aspect because you can see the medullary pyramids.
+1
amarousis
think of the belly of the pons as a pregnant lady. so you're looking at the front of her
+6
hello
which letter is CN IX in this diagram?
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miriamp3
there is no VI nerve. That's the thing. The VI nerve should be in the angle between the pons and the medulla. Parallel to the pyramid. It goes V then VII and then VIII. I make the same mistake and I thought it was the picture but there is no VI par in the photo. They know We count from superior to inferior.
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jesusisking
Don't G and H lowkey look like VII and VIII? I chose H b/c of that
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ljennetten
G and H are CN VII and VIII on the left side, while this guy has right sided hearing loss. CN VI is not labeled in this photo, but is the smaller nerve that arises medial to CN VII and us cut most of the way up the pons.
+1
prolific_pygophilic
Mother Fuckers took this with a disposal camera then deep fried it. What is this grainy ass picture
+1
soccerfan23
There's over a million pics of the brainstem on the internet and of course, the NBME picked the worst quality, most blurry one for this Q.
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yotsubato
Then why the fuck is it describing a mitral valve sound in the tricuspid area
+29
dr.xx
it's describing a splitting S1 โ consisting of mitral and tricuspid valve closure โ that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts.
+40
titanesxvi
tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound
+5
titanesxvi
tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound
+1
drzed
It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post)
The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound.
+16
alexxxx30
yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation.
+16
yesa
@drzed unless it's paradoxical splitting Ex] aortic stenosis, then it is aortic valve closing first at S2.
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welpdedelp
Superior rectal comes from the inferior mesenteric vein which comes from the splenic vein --> portal veins
Thus, this dude had cirrhosis so it would "back-up" into the superior rectal vein.
FA 2018: p360
+16
nc1992
Superior rectal not superior mesenteric. Took me a minute
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hyperfukus
ugh am i ever gonna get these right EVER
+5
titanesxvi
why not the inferior mesenteric, since the superior rectal drains there
+2
thomasburton
@titanesxvi think it is because question says direct which is why superior rectal
+2
lilyo
thomasburton, so are they asking what vessels do internal hemorrhoids directly drain into? The order is Superior rectal vein--> Inferior mesenteric vein--> portal vein.
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thomasburton
Yes exactly, so they do eventually reach IMV but not 'directly'
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pg32
Also worded poorly because the varicosities are connections between the superior rectal and the middle/inferior rectal veins of the systemic circulation. So the blood could be in both the superior rectal vein and the middle/inferior rectal vein as that is what a varicosity is.
+3
snripper
You just gotta know indirect vs. direct hemorrhoids. In this case, it's an indirect hemorrhoid (superior rectal vein) because of the rectal bleeding.
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jesusisking
@titanesxvi DrDoom explained it pretty well below: "Defining tributary: https://i.imgur.com/2zDxPbW.png Nice images make the term easier to recall. Smaller streams "pay tribute" to larger rivers (by flowing into them)"
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ht3
you're definitely not alone lol
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yotsubato
And its not in FA, so fuck it IMO
+1
link981
I guessed it because the names sounded similar :D
+18
yb_26
I also guessed because both words start with "glu")))
+30
impostersyndromel1000
same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle.
+1
jaxx
Not a clue. This was so random.
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mkreamy
this made me feel a lot better.
also, no fucking clue
+1
amirmullick3
My immediate thought after reading this was "why would i know this and how does this make me a better doctor?"
+10
mrglass
Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess.
+6
taediggity
I literally shouted wtf in quiet library at this question.
+2
bend_nbme_over
Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol
+25
drschmoctor
Is it biochemistry? Then I do not know it.
+5
jesusisking
I Ctrl+F'd glucosamine in FA and it's not even there lol
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batmane
i definitely guessed, for some reason got it down to arginine and glutamine
+3
baja_blast
Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic.
+2
feeeeeever
Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing
+1
schep
no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle
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flvent2120
Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least
+1
nala_ula
Omg literally the same thought process I had, that phrase through me off!
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skonys
How can it be SCC if it says there isnt squamous organization. I thought of pulmonary carcionoids because it's the only other pulmonary tumor that causes paraneoplastic SIADH.
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epiglotitties
@skonys in this case they're abbreviating Small Cell Carcinoma to SCC not Squamous Cell Carcinoma
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"I think there's no intervention necessary here. Newborns should have mom's antibodies. Related. Pay attention to the first bullet point, its a testable concept." reddit.com/r/medicalschool/nbme_7step_2_5_questions/