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Welcome to maxillarythirdmolar’s page.
Contributor score: 35

Comments ...

 +4  (nbme16#11)
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uYo olduhs eb ntihgnki fo montsgeih klie cneotsrE.ccou heTy ahd a GU crdreopue nda ubtsusnqee dcciara seu.sis

Whne I aerh tofs S1, i ihtkn tath the iapettn umst veah adh a suesi thwi teh clnoigs fo ihrtee hte mailtr ro cursitpid Plagiyn ods,d sthi lduhos be eht mtrali .leavv You olsa eerh na yealr iitsoalcd urrmm,u so oyu mgtih eb hitnking oleumv evlooard 3.()S

baja_blast  You're almost certainly right that it's mitral valve endocarditis. The murmur is accentuated by Expiration, consistent with lEft-sided murmurs. On the other hand, rIght-sided murmurs are accentuated by Inspiration. Note the capital letters for a handy trick. God Bless Dr. Jason Ryan. +3

 -1  (nbme23#33)
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Bset tnocmme i adre aws to ratte iths ilek si't a maVIPo. uYo oldwu egt all theer elrlamceoctltobyei/et en.ascdstruib


 +2  (nbme23#36)
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lekyiL na ntonbiiihi fo .dha-re1lsyxyo2 hisT is eth smot mmnoco of hte neailcotgn aarledn rtPesesn in fyannic ro dcohdi.lho

reAthon tposmym yeth aym veah atth I've eesn udroan si tvn!omi!ig oTko me a lhewi ot nidf ,it btu thye rae lats ntsgiaw by ianvgh on ,etoosrnelad so teh slso fo oytlletsrece is isucnag sieaedrcn .PCI

 +2  (nbme23#42)
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heT qieunsot yass eyht n'tod oeprdnss to atanidsc ENTH asks hwhic yuo to yfdtiien hchwi rgud si teh mtos tficeefev at gpnirpsusse icad dcr,opnituo ONT twha eth tmos iefcteevf tcanadi .si The wnrsae is I.PP's

I llwi asy, evhreow, I aws gloikon fro eghmtnosi lkei d.oietocetr

drdoom  lucid. nice catch. +1
maddy1994  WHY not blockage of h2 receptors +3
krewfoo99  @maddy1994. PPI are more effective than H2 blockers in suppression of gastric acid +1

 -2  (nbme23#12)
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AF ,91 g.p 503 - May ees iMlatr urggtoraieint due to irpaemid almrti vavle cusrelo.

I lswaay fnid ti nrmtiaotp ot emberemr thta noce uoy egt togolpyah ehmerewso in het ahrt,e uoy nac xcptee thypgaolo rehewevrye enbhdi i,t rove .mite

oS ni tsih aesc ouy tatrs hwit MCH tg-;& Matlir rugreg tg&;- AL oildaitn tg-;& Ai.fb ;g-t& L/ALV ufaielr &-;tg Pmlu deame t&;g- RHF t-;&g ct.e

'stI alaysw a mettar fo .tiem

mario  wrong q bro @ maxillarythirdmolar +
usmile1  nope right question. he just went even deeper into the answer. +

 +4  (nbme21#50)
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olL hhhu salo het scioadph si litrleyla aretcfdru ni eht X-yar

 +1  (nbme21#39)
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'mI rues st'i aretled to hte caiivttagn tefefc of lositoCr on stamaNlertplnhl-hea,iyfs-theaomennryeen reongtnciv EN to ip.E dnoSus elki a rcsitisnegy htnig to .em 38)A(.F

kevin  It's permissive because without cortisol Epi wouldn't be able to attain its full effect +

 +0  (nbme20#25)
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herWe edos hte leor of 1B oantltsmiiu of SRAA oecm nito thsi? dn'Wutlo hte B1 noicta ucsea seaderec ?RSAA htTa gnieb adis, I nac asol drsndnauet if hsta't a nogl mert gthin adn itsh si a quieotns uotab the edmiamtie f.?.esceft.

Subcomments ...

submitted by usmleuser007(377),
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reTta thsi klei a oImPVa Watrye( eahr,riad aohrharcdlyi = deeucdr HCl in hte ,mluen mp;&a aiaep)klomyh

ihst iwll elad ot tabeimclo odicssai td/ sslo of baircb in osotl

btl_nyc  Chloride is increased though. +  
maxillarythirdmolar  This comment is gold. @btl_nyc, this is actually accute. you would expect hyperchloremia +  

submitted by usmleuser007(377),
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PIP dffie-s:stcee + deseiacnr kirs ofr C. fdif + seIaencrd rski orf sepr nsoficetin + acn eacus seaoapgnhymi + aesdecre pbrtsoonai fo (+a2C, M,+2g a&;mp )oinr + aersceidn risk fo icoteotoorps ihp ratcresuf (d/t owl muers mu)cclai

imnotarobotbut  That's not the right answer tho, the answer is the binding of PGE to it's receptor +  
tinydoc  Can someone explain to me why the PPi answer is wrong if it increases the risk of C Dif wouldnt that also cause severe diarrhea. PPIs make a lot more sense to be given to this patient in the first place. +1  
maxillarythirdmolar  Keep it simple, stupid. +1  
roaaaj  @tinydoc You are correct about PPI increasing the risk of C. diff, but there was no history of antibiotic use. +  

submitted by sympathetikey(1265),
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I ees twha erte'hy yagsni (isth aws my onsdce hcic)oe btu at hte esam teim I feel ielk a uckbpa of bodlo dulwo teaavict eth eearorbprocts dan uesca deeadcres ymehpicsatt tcayitvi to het AS am;&p VA

sympathetikey  (choice E) +  
meningitis  Could you elaborate? Is this related to: less "preload" from mother circulation causes lowered HR? +  
meningitis  Or backflow of blood and causes a Reflex Bradycardia? still confused on this question. +  
kentuckyfan  So I think the subtle difference in choice E is that there would be a negative CHRONOTROPIC effect, no inotropic effect (contractility). +9  
maxillarythirdmolar  if anything, inotrophy could go UP not down as diastole prolongs and LVEDV increases --> Starling equation bullshit +  

submitted by gh889(117),
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osriopscnem of hte ocnmom alnpreeo verne as ti rapsw dnaour eht ncek of teh ilafub sueacs cereeasdd nsianetos ofrm the siilrcpeuaf poenrlea en,rev renopbelssi rfo het laartentraoel tseapc dna omdrus of the gle adn tofo

eDpe nelepaor rneve is rensoys to the cwebeaps wtenebe teh ullhxa nad d2n iidgt


maxillarythirdmolar  You might be able to damage the superficial peroneal nerve with damage to the lateral malleolus but the description in the stem has deficits in the end targets of both the deep and superficial peroneal nerves +1  

submitted by mousie(211),
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urYo uitaiyprt rpcolatto llsce yrpyherhtpo gunird rngcenypa ot rupeodc eannsiigrc atsnumo fo ricolnpta - rtap of the ypahopooilytgsh of Ssehnhe'a n.y.esd.mro sceandrie oldbo lsso grundi rylvedei nca sueac ehcmsici sscneoir fo aitpuiryt

tinydoc  I thought the elevated Estrogen and progesterone depress the function of Prolactin until delivery. I guess you needed to know that it decreases its function by downregulating receptors or something as opposed actually decreasing the prolactin production. I picked gonadotrophs. This was a fair question but I reasoned it out and arrived at the wrong conclusion. +7  
maxillarythirdmolar  Specifically, the estrogen is stimulating lactotrophs as progesterone is preventing the prolactin from actually working on the breasts. So it's the estrogen that is stimulating the lactotrophs to grow, and you would see the effects of this growth if it weren't for the progesterone preventing the action of prolactin (their secretory product) on the breasts. +9  
dul071  why not somatotrophs. she's understress. wouldn't that increase the production of GH +  

submitted by cbrodo(58),
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heT prioosetr umlonsc cu(Faisulcs cucFunasssuteacl/ui grlac)sii rcyra ifninmtoaor to hte nbira nrrgeagid ororpitpcponi,e vrii,obant caidmeirvstnii ouhtc nad sre.pesru ycPshila amex dngisnif uggsest a osieln rehe he(t nsmhialipocta ttrac riscear ncpiknppa/rii dan atrretmue,pe nad eesht rwee nlro.a)m eicSn eht eatntip has omaabnlr nisdfing in the rlowe eetmriis,txe nda raonml niidgsnf ni teh erupp ,smeixretiet eth swnrae is casicFusul lscgaiir. isTh is ecbusae tinorfaniom morf dyob erasa bweol eth evell fo T6 si icaedrr by icliarsg nad rinitoaomfn mfro ybod aears evboa eth velel fo T6 is eadrirc by snuectua.

kai  kick Goals (gracilis) with your feet Cook and eat (cuneatus) with your hands +3  
temmy  i remember gracilis is for legs by saying i have graciously long legs and they are inside while arms can spread out to remember their orientation on the spinal cord +4  
jess123  I remember it as gracilis = grass so feet haha +4  
link981  Just to add found on page 492 on FA 2018. +  
charcot_bouchard  Hey Temmy, I can spread my legs too :) +  
maxillarythirdmolar  I can't feel GRACIE's ~fine touch~ as she ~vibrates~ my balls. +3  
cat5280  Could someone please explain why you were able to eliminate the spinocerebellar tracts? +1  
drzed  Lmao I remember gracilis because of the gracilis muscle in the legs! +3  
alexxxx30 spinocerebellar tract does 4 things to know 1. proprioception in the Romberg test 2. intention tremor if damaged 3. shin to knee test 4. dysdiadochokinesia (being able to rapidly pronate/supinate the upper extremity) yes the patient has proprioception issues, but the other symptom of vibration loss points us more to a fasciculus gracilis issue. If the patient had presented with proprioception and and intention tremor then we would think spinocerebellar +2  
alexxxx30  adding to my comment^ I would commit these 4 things to memory as I have gotten several questions concerning this topic (there were 2 questions on this exam where spinocerebellar tracts are involved). Memorize them and it might get you 1-2 extra points! +  
solidshake  Just to clarify a point, Spinocerebellar tracts are not tested by the Romberg Test. Romberg tests conscious proprioception that is done by the dorsal columns. Spinocerebellar tracts are used for Unconscious proprioception. Look up tabes dorsalis in First Aid. One of the positive indicators is a positive romberg test, which shows that the dorsal columns have been damaged thus affecting conscious proprioception and thus impaired balanced on standing with the eyes closed +  

submitted by beeip(123),
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hisT sah enbe a thogu epoctcn for em ot t,eg tbu I hiknt Im' lfainly :heert

Teh tsme si renisgdibc rryampi andarel f,nunyiieiccfs ro dds'

  • ACHT si nebgi pcerdo-euvrod to ltitasume het saelnadr ot ecrdoup roosc,lit tub eyht tn'ca pdrsneo, teierh eud to rahtpyo or tonrudtcsei BT,( imtoueun:am R4D, .)tce
  • ehT rtfsi 13 onmia isdca fo ACHT can eb cdaleve ot mfor αHSM-, chihw tesmuisalt ecaeymtslon, uicsgan nmytirnoipptgheea
jotajota94  Good job! Also, cortisol is involved in maintaining blood pressure. which was decreased in the patient. +7  
tinydoc  Decreased Na and increase K+ --- Hypoaldosteronisim Hypoglycemia, and hypotension --- Hypocortisolism so the adrenals arent working ---- adrenal Insufficiency the Hyperpigmentation comes from the increase ACTH as ACTH is from Proopiomelanocorticotropin. SO - increased ACTH also increases a -MSH ---> Hyper pigmentation. +10  
hungrybox  thank u for this answer +  
bilzcop  Ugh! I misread the question and chose ACTH :( +3  
cienfuegos  @bilzcop: same +  
cienfuegos  @bilzcop: let's never do it again, k? +1  
maxillarythirdmolar  Why does this patient have elevated BUN and creatinine?? +2  
lovebug  @ maxillaryhidmolar > I don't know exactly. but maybe.. Low hypo-adlo -> our body lose water -> hypo-volemia -> Decreased GFR -> Increased Cr,BUN. If I'm wrong. please correct me. +  

submitted by whoissaad(75),
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eehrW si hsit eenv ?orfm My n'sdim iongg ahy eriw yrintg ot nareddtsun

sahusema  Hardy Wineberg equilibrium square root 900 = 30 1/2 of all offspring will be carriers so 30*.5 = 15 simple as that +6  
maxillarythirdmolar  this deserves a million upvotes. +1  

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hiTs is twah I thgtouh tbu ont ersu if ’ist rteo.crc Treeh si a WorUld q werhe ti sicbesder tctsdraimn-nooiai fo orltciso nad pneineip.rhe iCootlsr isntifgclyina sehcnane teh efftce of eip eecabsu coroilts hsa a imsepisvre ftcefe no mnaiginatin hte gneairdcer oees.prcrt

194orbust  per UWorld, "cortisol exerts a permissive effect on many hormones to help improve the response to a variety of stressors. For example, cortisol increases vascular and bronchial smooth muscle reactivity to catecholamines". FA also uses the effect of cortisol on catecholamine responsiveness as the lone example for a permissive drug interaction (FA2018 pg 229). The difference here is that we're talking about exogenous glucocorticoid and adrenergic agonist. I guess it was expected for us to assume that the mechanism is analogous for the analogous drugs +11  
maxillarythirdmolar  I'm sure it's related to the activating effect of Cortisol on phenylethanolamine-N-methyltransferase, converting NE to Epi. Sounds like a synergistic thing to me. (FA.83) +3  
feeeeeever  My logic is probably flawed, but I also thought that if cortisol has the ability inhibit COX, LOX, and NFKB you can reduce inflammation and bronchoconstrictive mediators. Therefore, the B2 agonists would have a greater effect since things like LTB4 will be reduced. +1  
feeeeeever  *LTC4, LTD4, LTE4 for bronchoconstriction, my bad +1  

submitted by lnsetick(90),
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  • AncreoPi = yuro pirstma lelms klie an PEA
  • eMcUneR = erh’ets no MROO in yruo esar nscei ryeth’e lluf of xaw
  • RECY-Cen = whne yuo irs,eCeEc yuor ersop aer nYCigR
  • eEBsoacuS = BEuSm si PiSgEEn tuo fo ryuo rpeso
hungrybox  as an ape i'm offended +28  
dr.xx  stop being an ape. evolutionize! +6  
dbg  as a creationist i'm offended +11  
maxillarythirdmolar  Also, Tarsal/Meibomian glands are found along the rims of the eyelid and produce meibum +  
snripper  So why is it apocrine? The dude is EXERCISING when playing football. +2  
qball  The question asks about "the characteristic odor" i.e. body odor coming from the APEocrine glands. The Eccrine glands secrete water and electrolytes. +1  

submitted by haliburton(209),
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-eriP ro psoutpratm aoodtmycirhayp P)CP(M si a ear,r afett-enirhnilge etarh desasei of ecrnual nrogii dan is zdecetriahrac yb etahr fluriea of sduend onest etbwene eth lnifa eskwe fo ncerynagp dna 6 mhtosn erfta ee.lridyv kinl ot pmbeudheT nalclcii utripce of CPPM scrpnsoredo to a dltedai yroipcathoydma D)CM( itwh sgsin fo revees tearh .lerifau

maxillarythirdmolar  For anyone wanting to understand why^ the tl;dr is that prolactin gets cleaved into two toxic metabolites. Treatment is something like bromocriptine (and therefore no more breast feeding) to stop prolactin release. Lastly, you can treat with regular HF meds. +1  

submitted by cantaloupe5(72),
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Hhreh/dpyptyyrmooisi is ngdieoasd itwh THS /w flxere to T4 ti(hs sjut tlsle teh abl if SHT is raonml on’td echkc 4T btu fi STH si orab,lmna kcche T4 t.o)o THS t’snwa na iopnto so T4 si hte sbte rwasn.e

hello  I don't get why this was downvoted... +2  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +  

submitted by assoplasty(91),
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I tknhi eth eopnctc etrhy’e esttgin si eth escaredni TBG sleevl ni cgennpry,a nad ton stju hhirymoeypridts ni nr.eaegl

enhW rngcesnie rfo oipht,yihpydrhyosrem/ SHT elelsv are YLASWA tefrlilepnaeyr ececkdh easebcu ethy are emor itenivses to mitneu eedfencsfir ni 3T4/T. nOeft meist THS vlesle acn eemstdnrtao a agcnhe even nhew T4T/3 veells rae ni hte bliilnsaccu ae.gnr Teh lnoy nxctopiee to shti uowdl eb in gyacepnrn (and I gsseu yeabm ievrl if?uelra I boutd hyte owdlu kas isth o) hHgi tnseeogr lveles vnpesret het rvile omrf knaibgre ondw G,BT lignade to asneicerd BTG eesllv in teh s.rmeu hisT nibds to refe ,T4 cseanidger eth omtuan of aaveilabl eerf 4.T sA a oartynpcsmoe eahnmis,mc THS seelvl aer artlynitens drcneiesa dan the ARTE fo T4 tdiuoocnpr si ecnersdai to pneeihsrl enlbeais erfe T4 lvele.s ewrvoHe hte TOATL namuto of 4T si se.anecdri

heT tionuqes si ngkisa owh ot miornfc thieohpyysdmirr ni a ptrngean aowmn &t;-g- oyu eend ot cekch REFE 4T slvlee ee(buacs htey sldohu be lroamn ude to casmoorpyetn ers).sopen uYo tocnan hckce THS yull(uas edvtelea ni crynnapeg ot scotmnaepe rof sinaeedrc )BTG, adn ouy nacont hkecc ttaol 4T svlele wll(i eb i)ers.caend You got hte rsneaw itghr trheie ywa tub I tnihk hsti is a dtefefrin roanniegs orwht ni,seirndocg eaebcsu yhet acn sak ihst tnpceco in toehr centxsto of gheem-onir,estyprs nda if htey etdisl STH”“ sa an aeswnr ihecco ttah oludw be i.nectorrc

hungrybox  Extremely thorough answer holy shit thank u so much I hope you ACE Step 1 +8  
arkmoses  great answer assoplasty, I remember goljan talking about this in his endo lecture (dudes a flippin legend holy shit) but it kinda flew over my head! thanks for the break down! +2  
whoissaad  you mean total amount of T4 is "not changed"? 2nd para last sentence. +  
ratadecalle  @whoissaad, in a normal pregnancy total T4 is increased, but the free T4 will be normal and rest of T4 bound to TBG. If patient is hyperthyroid, total T4 would still be increased but the free T4 would now be increased as well. +1  
maxillarythirdmolar  To take it a step further, Goljan mentions that there are a myriad of things circulating in the body, often in a 1:2 ratio of free:bound, so in states like this you could acutally see disruption of this ratio as the body maintains its level of free hormone but further increases its level of bound hormone. Goljan also mentions that you'd see the opposite effect in the presence of steroids and nephrotic syndromes. So you could see decreased total T4 but normal free T4 because the bound amounts go down. +1  
lovebug  Amazing answer! THX +  

submitted by temmy(127),
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saleep ephl dcicgnaro to iwstren nqauoite eth tenptia sah a anmlor oanni apg

ergogenic22  winter's formula is to look at the compensation to see if it is appropriate. PCO2 = 1.5[HCO3-] + 8 +/- 2 In this case, 1.5* 10 (Pt's bicarb) +8 +/-2 = 21 to 25 Pt's PO2 is 23, so compensation is appropriate. If PCO2 was below 21, it would be concomitant respiratory alkalosis +5  
ergogenic22  in other words, winter's formula is not necessary for this question +2  
the_sacramento_kings  lol unless you want to make sure its not A. +1  
hello  @ergogenic22 Someone might use Winter's formula to rule out choice A. +  
maxillarythirdmolar  respiratory depression of alcohol should rule out "A" +  
baja_blast  Isn't the low pCO2 enough to rule out A? +1  

submitted by hayayah(1057),
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foitDinien fo ettduajmsn rdoe:disr

loomainEt posymmts ,g(e etiyaxn, )ndeeiorpss atht roccu nihiwt 3 mnohst of na tiifeebldina hslocyiaocsp sestrsro g,e( r,oedciv sl)isenl tailngs tl;& 6 ntohsm coen eth oretsssr ahs dden.e

If sptommys prtsies t;g& 6 motnhs tfare ssrotres ,neds it is AG.D

hello  Yep, and I think what we are supposed to take from this Q is: The only info. we have for this patient is that he ended chemo 2 months ago and has been calling the doctor a lot -- this is supposed to mean he has been calling a lot since ending chemo 2 months ago. His frequent calls starting after ending chemo and within 3 months of the stressor fits with the above-stated definition of "adjustment disorder" with anxiety. I stressor in this case could possibly be either the actual illness or the ending of chemo/treatment. It probably does not matter much in this case. +3  
charcot_bouchard  I think doing uw done me wrong here. Adjustment disorder isnt diagnosed when symptom match another disorder --- it was like never a right answer. But ofc its right answer in nbme +5  
maxillarythirdmolar  Just to add to that, the tingling in his fingers may seem like a distraction/it probably is. Likely has some relation to his Chemo. +3  
j44n  shit I thought this poor guy had OCD with all the repetitive behaviors. +  

submitted by neonem(556),
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sciutbeOrvt rhatpuyo uesacs a arltsepno miaeaozt t-;g&- hwen ndp,goorle rutualb amaged een.ssu Tish edsla ot na etacu utlrbua esncisro, aiahzctrceedr by tirocnec uspgl in eht urablut etsysm as nese in hte gaiem

meningitis  Does anyone know the relevance of the stem saying: "during this time she also has been crying frequently"? +37  
usmleuser007  Think the postrenal azotemia is d/t her pregnancy. With the increasing in size fetus, the pelvic cavity is being compressed and thus there is pressure on the ureters. This leading to the presentation. As per above --- the crying maybe just d/t her pain and emotional stress caused by worrying about possible complications regarding her fetus. +4  
maxillarythirdmolar  My gut tells me it must be some sort of transient change in placental size with hormonal changes. It's reminiscent of what you might expect for breast changes during the menstrual cycle, imo +  
j44n  or maybe the fetus is literally crushing her ureters into the wall of her pelvis and shes got an infected kidney +1