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Comments ...

 +1  (nbme22#49)

I wasn't sure, but then I realize he is going to die, he is in a hospice + the best you can do is made him feel without pain. BUT at the end what made me decide was The reason of the medication. At this point you really don't care about controlling everything else.

Subcomments ...

submitted by yotsubato(1019),
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yhW cnat itsh eb esa?vaitxl tBho wuldo eusca iactemobl aklssiola wiht ?

sup  Laxatives would cause an anion gap metabolic acidosis due to loss of bicarbonate in the stool. You would see hypokalemia though as seen in this question. +1  
miriamp3  it took me a lot of time choosing between laxatives and diuretics and at the end I choose diuretics. but I didn't realize that the only thing I had to do was check if were a anion gap or not. +  
snripper  Why would laxatives cause anion gap MA? Isn't it similar to diarrhea? +  
castlblack  The above comments are incorrect. Diarrhea is a cause of normal-anion-gap metabolic acidosis (D in HARDASS from FA). Laxatives are wrong because they would lower HCO3- but in this scenario it is high. The low K+ and Cl- fits either case though. +4  

submitted by mattnatomy(43),
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Aenwsr = C. (arceeDsed peticah LLDV ysssihetn)

Niitcoicn cdai = nNaici. cnNiia woksr yb:

  1. gtinIhiibn soilsilpy menor(oh eiveitnss lpsaie) in sdepiao is)suet

  2. iRguedcn aehipct LVDL tsnhsieys

johnthurtjr  Well color me surprised. I was completely thrown off here. +33  
miriamp3  @almondbreeze go to the cardiovascular pharmacology you will see a draw of lipid lowering agents and you will find niacin en two places ++one on the adipose tissue and the second one in the liver by the vldl production. in the text in the same page is also mention it FA 2018 pg 313. +  
djeffs1  I still don't quite see how C corresponds to those 2 processes... +  

submitted by usmleuser007(395),
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uJst otne hyw ohter rswneas era tno re:corct

  1. npn&bsgoy;Ehpois an eeidrnsca ronesnaec fo oivce sodusn hreda hnwe lcsiauntaugt eth sgln,u nteof uedacs by unlg ciodonlsonait nda ss.rbifoi

    • a. tI si deu ot ndhnaece rsasnnotsmii fo efnhhuc-qiyger unosd sarcos lufd,i chsu as in mloanarb lnug ssuie,t hwit wreol seerfqecnui rliedeft o.tu
  2. eirspeWhd yoqo&;crsirleeustrpebpfn ot na snidercea dulesosn n;ioibbedsfnr&wnssop;th&negpp nigdur lcusaantoitu hiwt a soehsptotec on the nulg fedisl no a sniteatp’ rotso.

    • .a uUaylls kpnseo nssdou of np;meds&osbprilaves;wp&nehub yb hte ittapne uldow not eb rhdae yb eth nlancciii agasutcultin a ugnl dfeil thiw a .tctoeshepos

    • .b Hrewove, in reasa of eth lnug eewrh htere &nsnlgsi;pub oos,dnaotiicnl ehste swrieehpd onkpes dsosnu by het ntaeitp c(uhs as ysgani ’-ntn‘nneie)iy lwli be yrlelac hedra ghorhut the soecet.phtso

    • .c sihT aerinecs in dnosu ssexti cbeeusa udsno tavrlse erstaf and uhts iwht wlroe loss of ytsentnii urhgoth iqildu or sdoli (l“fidu mssa” ro “odils s,sa”m ,secteivylper in het nul)g ruevss ogssuae (rai ni teh guln) .imdea

    • d. pWshedire toqlpiucoery is a lancclii tets ltplicyay errfmepod ginrdu a ecdilam alcphysi aioaitnnxem ot vaeulate for teh epcrsene &;pnnflsoubg iinsotnaocold, whchi ouldc eb desacu yb arcenc (lodis ms)sa or munaeinop di(ulf sa).ms

titanesxvi  why not wheezing? +  
miriamp3  @titanesxvi because the dx is CHF +  
leaf_house  I get why crackles are more likely in CHF, but wouldn't it also cause whispered pectoriloquy, if fluid allows better transmission of sound? +  

submitted by bubbles(69),
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ihnoCcr ernal nyncceifi:ifus

1) poro ospetpahh cealeancr ;-t-g& high rsmue arnogncii opsproshouh

2) ghih emsru hposepaht ;--gt& eoscpelxm iwht alindtve tcnoia aC -&-g;t aC safll

3) Ca allsf ;->- isgetrgr PTH xisa

4) nykedi irlfaeu -;g-t& esrdeaecd vatcytii of yo-1lyearxdsh ta the inyekd g;-t&- ssel aolcitrcil

makinallkindzofgainz  this guy renals +6  
paperbackwriter  Someone please help me with this (always trips me up): PTH causes increased vit D production in kidney... are we assuming the increased PTH can't catch up with the kidney failure? Is it the level prior to PTH compensation that they want? D: +  
miriamp3  @paperbackwriter what it works for me ;;;; is find the first abnormality so CKD low calcitriol (no D vit) ---> is gonna increase PTH ---> the kidney are not working (chronic, they don't tell u recently- you can;t revert a CKD so the kidney never going to catch up) --> increase inorganic phosphorus.--> always start with the problem. I also use this for celiac and types of shocks. start with the problem, and trust yourself. +2  
paperbackwriter  @miriamp3 thank you! I will try out your strategy next time!! :) +1  
snripper  I thought renal insufficiency -> inability to reabsorb phosphate at PCT -> decreased phosphate? +2  

submitted by haozhier(17),

I chose C because I thought it has been four weeks so it must have been acute tubular necrosis. Can anyone explain? Thanks!

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. +  
jesusisking  I thought the same thing so chose C as well! +  

submitted by seagull(1539),
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Wtha a trbieerl itpcur.e eTyh yhet rdvceeo up atpr of it hitw e.snil FTW

sympathetikey  Agreed. +14  
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 +11  
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? +2  
catch-22  You're looking at the ventral aspect of the brainstem. +10  
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 +4  
hello  which letter is CN IX in this diagram? +  
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. +  
jesusisking  Don't G and H lowkey look like VII and VIII? I chose H b/c of that +  
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. +