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submitted by imgdoc(72),

I think its the right MLF (area C), not the right abducens nucleus that is lesioned on the cross section. If the abducens nucleus were lesioned she wouldn't have abduction in her left eye. The MLF mediates cross talk between the abducens nucleus on both sides to the MLF on the opposite side (2 abducens nuclei, 2 MLF one on each side). In her case, her right MLF wasn't functioning hence why she was gazing left but her right middle rectus wasn't contacting to mediate leftward gaze.

This picture helps: http://what-when-how.com/wp-content/uploads/2012/04/tmp15F9_thumb.jpg

imgdoc  *medial rectus +  
quip13  This shows the MLF pathway in a saggital cut: https://ars.els-cdn.com/content/image/3-s2.0-B9781437719260100128-f12-08-9781437719260.jpg +  

submitted by armymed88(29),

A little math here.. pH is low --> acidosis pCO2 is high --> respiratory Normal compensation should be roughly a 1 (acute) to 4(chronic) increase in bicarb per every 10 increase in pCO2.. Its lower here, so clearly not compensated and indicated additional drop in bicard --> add on metab acidosis

hello  Hm, what do you mean by "normal compensation?" Are you talking about the bicarb should be increased? Are you saying that a normal compensation would be metabolic alkalosis? Would metabolic alkalosis be an increase in bicarb? +1  
kateinwonderland  How do you know which one has bigger contribution in this situation where there's increased CO2 and decreased HCO-, both indicating acidosis?? +  
yb_26  normal kidney compensation would be an increase in bicarb reabsorption => increased serum bicarb. This pt has low serum bicarb => concurrent metabolic acidosis +  

The rhombencephalon would be on the actual fetus so just get rid of (D). The "black hole" that the fetus is floating in is the gestational sac so get rid of (C). Now I am no ultrasound expert but I know that the amniotic cavity eventually expands to fuse with the chorion thereby eliminating the chorionic cavity (B). In terms of where the amniotic cavity is shown in this image, I am not sure, so maybe someone can help but this leaves the yolk sac which typically appears within the gestational sac around 5.5 weeks.

kateinwonderland  At the end of the fourth week, the yolk sac presents the appearance of a small pear-shaped opening (traditionally called the umbilical vesicle), into the digestive tube by a long narrow tube, the vitelline duct. (Wiki) +3  
tallerthanmymom  But why does it look completely detached from the fetus? I eliminated yolk sac first because of this +  
makinallkindzofgainz  If you look reeeeeeeally closely, you'll see some signal between the yolk sac and the baby. Although you can't see the entire connection, they are connected. +1  
thotcandy  Pt is roughly 8 weeks pregnant so and typically by 9th week, Amniotic cavity has expended to fill entire volume of Gestational sac. So the entire black part around the fetus is GS/AC. +1  

So I got this one wrong because I thought that since he didn't have hepatosplenomegaly and ascites his liver was still fine, but I guess if he already has gynecomastia, hypogonadism and the ever obvious spider angiomata he's definitely still ok

Now that I think of it, you don't need hepatosplenomegaly to have alcoholic liver failure I believe.

bigbootycorgi  sorry my bad this was the wrong question i responded to but i still got this one (ED one) and the gynecomastia one wrong i think it's liver for this one because they say it has regenerative potential and because even though the small intestine has regenerative potential, it can apparently fibrose? i have no idea, i put small bowel +  
kateinwonderland  @bigbootycorgi : I put small intestine too. From what I've searched after, it says that liver fibrosis reversible -> no evidence of fibrous scarring +  
goodkarmaonly  Just to add to that, a cirrhotic liver is a small shrunken liver so you wont be able to find hepatomegaly anyways. The other signs are the stigmata of Liver disease +  

submitted by keycompany(182),

This patient has a pneumothorax. Hyperventillation is not enough to compensate for the overall decrease in lung surface area.

_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. +2  
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. +2  
kateinwonderland  Arterial blood gas studies may show respiratory alkalosis caused by a decrease in CO2 as a result of tachypnea but later hypoxemia, hypercapnia, and acidosis. The patient's SaO2 levels may decrease at first, but typically return to normal within 24 hours. (https://journals.lww.com/nursing/Fulltext/2002/11000/Understanding_pneumothorax.52.aspx) +1  
linwanrun1357  How about choice C, --ARDS? +  
bullshitusmle  there is no bilateral lung opacities as you would see in ARDS +2  
jesusisking  Was thinking some sort of infection b/c of the atelectasis so picked empyema but this makes sense! +  

submitted by ihavenolife(27),

Pg 360 First Aid 2019

Internal Hemorrhoids

-Visceral innervation (no pain felt), Superior rectal a., Superior rectal vein (drains to IMV), Internal iliac lymph nodes


External Hemorrhoids

-Somatic innervation (they hurt), Inferior rectal a., Inferior rectal vein (drains to internal pudendal vein), Superficial inguinal lymph nodes

kateinwonderland  Above pectinate -V:sup. rectal v -> inf. mesenteric v. -> splenic v. -> portal v -internal iliac LN Below pectinate -V:inf. rectal v -> internal pudendal v->internal iliac v->common iliac v->IVC -superficial inguinal LN (FA 2018 p360) +1  
sherry  Venous drainage above pectinate, most to the portal vein, some to internal iliac v via middle rectal vein. I think the real solid key here is that the clinical vignette suggests hepatic cirrhosis. +  
moxomonkey  internal hemorroids are not related to portal hypertension https://www.ncbi.nlm.nih.gov › pmc › articles › PMC4691702 also FA 383 anorectal varices are. now if you check FA it say Pg 359 First Aid 2019 Anorectal varices Superior rectal ↔ middle and inferior rectal all of them include in the answers options so? +1  

submitted by medskool123(13),

how did you know it was a strawberry hemangioma and not a port wine stain?I thought I had this one in the bank

kateinwonderland  Me too! TABLE 1 Classification of Vascular Lesions Vascular malformations (flat lesions) -Salmon patch (also known as nevus simplex or nevus telangiectaticus) -Port-wine stain (also known as nevus flammeus) Hemangiomas (raised lesions) -Superficial hemangioma (also known as capillary nevus hemangioma) -Deep hemangioma (also known as cavernous hemangioma) https://www.aafp.org/afp/1998/0215/p765.html +  
krewfoo99  Because they describe the lesion as cavernous vascular channels +  

submitted by medstruggle(10),

Why is it aphthous ulcers if there are no GI symptoms? Why can’t it be herpes zoster?

colonelred_  It’s just canker sores, they come and go. I think in herpes the gingivostomatitis really only happens when you first get infected. After that you just get recurrent cold sores. +1  
hyoid  Herpes zoster is not the same as herpes simplex virus. +11  
bigjimbo  you would see dermatome rash in zoster +1  
kateinwonderland  cf) Just in case someone wanted to know the causative organism of aphthous ulcers :The precise cause of canker sores remains unclear, though researchers suspect that a combination of factors contributes to outbreaks, even in the same person. Unlike cold sores, canker sores are not associated with herpes virus infections. +3  
charcot_bouchard  Herpes Zoster doesnt cause gingivostomatitis. Herpengina can cause vesicular lesion in mouth but happens to children in summer season by entero virus +  
drdeeznuts1  I'm wondering if this could be a mild case of Behcet syndrome without genital involvement +  
sherry  It sure can be Behcet or Pemphigus if the q provides us with more info. Canker sores just come and go for years with unclear mechanism. Also herpes zoster is shingles by VZV, not HSV1. +  

submitted by ameanolacid(13),

Atherosclerosis is the MOST common cause of renal artery stenosis...with fibromuscular dysplasia being the SECOND most common cause (even though it is tempting to choose this option considering the patient's demographic).

xxabi  Is there a situation where you would pick fibromuscular dysplasia over atherosclerosis if given both options? Thanks for your help! +4  
baconpies  Atherosclerosis affects PROXIMAL 1/3 of renal artery Fibromuscular dysplasia affects DISTAL 2/3 of renal artery +17  
gonyyong  Why is there ↓ size in both kidneys? This threw me off +2  
kateinwonderland  @gonyyong : Maybe because narrowed renal a. d/t atherosclerosis led to renal hypoperfusion and decrease in size? +  
drdre  Fibromuscular dysplasia occurs in young females according to Sattar Pg 67, 2018. +3  
davidw  Normally you will see Fibromuscular dysplasia in a young female 18-35 with high or resistant hypertension. She is older has a history type II DM predispose you to vascular disease and normal to moderate elevation in BP +3  
suckitnbme  @gonyyong there's bilateral renal artery stenosis. The decrease in size of both kidneys should be from atrophy due to lack of renal blood flow. +