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submitted by meningitis(310),

When standing up, the body normally activates sympathetic system to avoid orthostatic hypotension.

But since there is now an additive effect of the pheochromocytoma adrenergics, it will lead to a hypertension

(i.e: Double vasoconstriction = Pheo adrenergics + Sympathetic system)

sympathetikey  Brilliant. +3  
medschul  Would pheo have a normal resting BP though? +1  
meningitis  I was trying to justify these tricky questions but very true medschul.. It shouldn't have normal resting BP. Sometimes it seems these NBME always have a trick up their sleeve. Im getting paranoid lol +  
nala_ula  The reason why the patient probably has normal HTN is because Pheochromocytoma has symptoms that occurs in "spells" - they come and go. Apparently in that moment, when the physician is examining her, she doesn't have the HTN, but like @meningitis explained, so many adrenergic hormones around leads to double the vasoconstriction when the patient stands up. +6  
meningitis  Thank you @nala_ula for your contribution! Really filled in the gap Iwas missing. +1  
nala_ula  No problem! Thank you for all your contributions throughout this page! +1  
mjmejora  I thought the pheochromocytoma was getting squeezed during sitting and releasing the epinephrine then. kinda like how it can happen during manipulation during surgery. Got it right for sorta wrong reasons then oh well. +  
llamastep1  When she sits in the examination table there would be a normal activation of the sympathetic system from the stress of getting examined which is amplified by the pheo. Cheers. +  
sammyj98  UpToDate: Approximately one-half have paroxysmal hypertension; most of the rest have either primary hypertension (formerly called "essential" hypertension) or normal blood pressure. +  
hello_planet  FA 2019 pg. 336 +  


submitted by famylife(61),

This is strep pneumo, which has alpha hemolysis (green)

breis  How is this differentiated from Strep Virdans which is Optochin Resistant? Because Strep Pneumo would also be inhibited by optochin* +  
mjmejora  its strep viridans. Strep viridans has a "protected chin mask" and strep pneumo is "exposed" in the sketchy. +3  


submitted by seagull(840),

https://en.wikipedia.org/wiki/Blastomycosis#/media/File:Blastomyces_dermatitidis_GMS.jpeg

I believe this is actually disseminated Blastomyces due to the "Broad Based Budding" as seen in the picture.

seagull  However, given the stain and some of the features I now see that this is most likely Crypto. THey like similar. my bad +11  
mjmejora  oh what a catch! I also thought this was Blasto until you explained otherwise +  
drmohandes  Blasto = broad-based budding, the two 'circles' look equal in size. Crypto = narrow-based -unequal- budding. +5  
paperbackwriter  ^ I would disagree a little bit. "Broad based" and "narrow based" refer to how smushed the circles are. So narrow based is when the membrane bit they're sharing is small, and broad based is when they share a lot of membrane. So if just pinching off --> crypto, if they look stuck/have a flat membrane between them --> blasto +1  


submitted by neonem(451),

NRTIs are the main HIV therapy drug that can cause bone marrow suppression (not as common with NNRTIs). This class includes zidovudine, didanosine, emtricitabine, lamivudine, stavudine, abacavir. Zidovudine is most known for this side effect.

Nelfinavir = protease inhibitor azithromycin = aminoglycoside (not really used for HIV) pentamidine = another antimicrobial, mostly used for pneumocystis I think? Lamivudine = another NRTI but less known for bone marrow suppression

adisdiadochokinetic  Azithromycin is a macrolide, not an aminoglycoside FYI, and its use in HIV is primarily as prophylaxis at very low CD4 counts for, among other things, the mycobacterium avium complex. +5  
nbmehelp  How would we have known to choose Zidovudine over Lamivudine tho +5  
mjmejora  @nbmehelp the sketchy with Princess Izolde (Zidovudine) eating bone marrow was my only tip off +6  
niboonsh  you have ero bone marrow if you take idovudine +1  
niboonsh  the z's were supposed to be bold idk what happened. you have Zero bone marrow if you take Zidovudine +4  
t123  Zidovudine is also a very early NRTI developed. As a good rule of thumb, older drugs have worse side effects +2  
therealslimshady  Zidovudine Zaps your bone marrow (sorry) +1  


submitted by doodimoodi(39),

Did no one notice that the Odds ratio on the top left is wrong? Am I missing something? If you calculate it, it's 6 just like the top right one....

mjmejora  thats actually really funny +  
yex  Because I said so, applies here... :-/ +  
doodimoodi  Cant believe we pay $60 for this crap +23  
aisel1787  best comment doodimoodi) +1  
b1ackcoffee  that fucking threw me off on exam. I was like is there an effect modification by "Not drinking milk". the fuck! +  


submitted by uslme123(22),

This question makes no sense to me. She has an extremely low opening pressure yet has signs of increased intracranial pressure. Did they mean to put 32 cm H20?????????

uslme123  Standard lab values are incorrect, way to go NBME. +2  
wutuwantbruv  I think they mean to put mm Hg. Normal CSF pressure is about 100-180 mm H20 which equates to about 8-15 mm Hg. +2  
alexb  I lost a bit of time wondering about that ugh lol +1  
mjmejora  I thought there must be an obstruction in the ventricles somewhere preventing csf from getting to the spine. so pressure is low in spinal tap but in the head it must be really high. +  
donttrustmyanswers  Does anyone have clarification on this question? +  
llamastep1  Pseudo tumor cerebri can have normal ICP. Who knew +  
tyrionwill  Hi, mjmejora, MRI did not see anything abnormality, couldn't this mean that there was no obstruction in the ventricles? +  


submitted by mousie(135),

why does treatment of hypothyroid (with levothyroxine I'm assuming) increase risk for myopathy? I chose it simply bc its a common adverse effect of statins but I don't really understand how treating hypothyroidism at the same time would have anything to do with it ??? help please!

yb_26  They are just asking about side effect of statins, not about treatment of hypothyroidism +5  
mjmejora  Hypothyroidism is just a red herring. +  
ususmle  statins cause both hepatotoxic and mypopathy so I want for hepatotoxic:( I thought usmle expects different stuff +1  
drzed  Statins don't cause 'toxic hepatitis' they just cause a mild asymptomatic rise in LFTs that is reversible with discontinuation of the drug. The more worrisome side effect is of course, myopathy +1  
tyrionwill  statins cause both liver injury and myopathy in a dose related, so kidney failure increases their dose, which leads both liver and muscle risk elevated; Pravastatin is said less liver concerns but the myopathy, so choose myopathy when renal failure. +  


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