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Comments ...

 +3  (nbme18#34)

Mitral valve and teeth cleaning are key words for Strep viridans diagnosis. It is alpha hemolytic so it would have a greening reaction.

important mention to watch out for:

The optochin answer is incorrect because it says "inhibition BY optochin". Viridans is resistant to optochin so that answer is incorrect.

 +0  (nbme18#34)

Mitral valve and teeth cleaning are key words for Strep viridans diagnosis. It is alpha hemolytic so it would have a greening reaction.

important mention to watch out for:

The optochin answer is incorrect because it says "inhibition BY optochin". Viridans is resistant to optochin so that answer is incorrect.

 +1  (nbme20#17)

Possible explanation:

If the pt is taking a thiazide (which is K depleting), it might have also been given with a K sparing drug such as spirinolactone.

Spirinolactone has endocrinologic effects such as gynecomastia and galactorrhea.

sugaplum  I think you could only make this assumption if they said "patient is on standard htn tx" but since they gave the name hctz, would not be fair to assume they are also taking spirinolactone. I went with process of elimination on this one. Even checked access medicine's drug adverse effect profile...galactorrhea not listed for hctz

Subcomments ...

submitted by hayayah(603),

the majority of carbon dioxide molecules are carried as part of the bicarbonate buffer system. In this system, carbon dioxide diffuses into the RBCs. Carbonic anhydrase (CA) within RBCs quickly converts the carbon dioxide into carbonic acid (H2CO3). Carbonic acid is an unstable intermediate molecule that immediately dissociates into bicarbonate ions (HCO3-) and hydrogen (H+) ions.

The newly synthesized bicarbonate ion is transported out of the RBC into the plasma in exchange for a chloride ion (Cl−); this is called the chloride shift. When the blood reaches the lungs, the bicarbonate ion is transported back into the RBC in exchange for the chloride ion. The H+ ion dissociates from the hemoglobin and binds to the bicarbonate ion. This produces the carbonic acid intermediate, which is converted back into carbon dioxide through the enzymatic action of CA. The carbon dioxide produced is expelled through the lungs during exhalation.

hungrybox  Amazing explanation. Thank you!! +  
namira  in case anyone wants to visualize things... https://o.quizlet.com/V6hf-2fgWeaWYu1u23fryQ.png +3  
ergogenic22  CO2 is carried in the blood is bound to hemoglobin, known as carbaminohemoglobin (HbCO2) (5%), dissolved CO2 (5%), bicarb is 90% +3  
pg32  Nice explanation, but can anyone clarify how we know from the question that we are measuring HCO3 rather than dissolved CO2? +1  
qball  @pg32 This question is asking about what accounts for the LARGER amount of co2 and the HCO3 buffer is about 85% of this transport and dissolved C02 is about 5-7%. https://courses.lumenlearning.com/wm-biology2/chapter/transport-of-carbon-dioxide-in-the-blood/ +  

Arthropod for sure, but for the record I'm pretty sure this was Chikungunya Virus. Only got this from a UWorld question as I hadn't seen it until then, but apparently the arthralgia is really bad, which is what drew me to the answer.


meningitis  More like Zika Virus (Same a. aegypti vector) since it says she has rash associated to her bone and muscle pain. I had Zika one time (i live in Puerto Rico). Remember also dengue and Zika are Flavivirus. Dengue can cause hemolysis (hemorrhagic), and Zika is associated with Guillen Barre and fetal abnormalities. +7  
nala_ula  I'm shocked that I found a fellow puerto rican on this site! Good luck on your test! +  
namira  dont be shocked! me too! exito! +1  
niboonsh  Dengue is also known as "bone break fever" which makes me think its more likely to be dengue due to the "excruciating pains in joints and muscles". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242787/ +8  
dr_jan_itor  I was thinking that its Murine typhus transmitted by fleas +  
monique  I would say this is more likely scenario of either Dengue or Chikungunya, not Zika virus. Excruciating pain is common in those, not in Zika. Zika has milder symptoms of those three infection. +1  
jakeperalta  Can confirm that Chikungunya's arthralgia is pretty horrible, from personal experience. +  
almondbreeze  UW: co-infection with chikungunya virus with dengue virus can occure bc Aedes mosquito is a vector of both Chiungunya, dengue, and zika +  

submitted by sympathetikey(618),

CD4+ cells activate B-cells which form follicles and cause enlargement of lymph nodes. Therefore, in an AIDS patient, to enlarge the lymph nodes, the CD4+ dysfunction must be resolved.

breis  Yea i get that, but if the patients CD4 was ~35, how in the world did the CD4 count rise enough to stimulate B cell proliferation...? I don't get it +2  
namira  The only thing i can think of is that: the cd4 count that is given was taken prior to having started the antiretroviral therapy. Since the question asks about "improved function", maybe its referring to the therapy actually being effective and its managed to increase cd4 count and function so as to be able to contribute to lymph node enlargement due to myco. avium +8  
kamilia20  I though it transfer to a lymphoma,OMG +  

submitted by laminin(10),

can someone explain why it says he has an 'intact' PTH concentration...is it to let us know that the PTH concentration is a result of pathology? and what's his dx? thanks!

yotsubato  I swear they make up some of this stuff. Like whats up with the thirst, urination, and peptic ulcer diseases. +2  
redvelvet  hypercalcemia can cause nephrogenic diabetes inspidus; so thirst, urination. hypercalcemia can also cause peptic ulcer disease. His symptoms are all about hypercalcemia due to hyperparathyroidism. +1  
namira  "Hypercalcemia can cause renal dysfunction such as nephrogenic diabetes insipidus (NDI), but the mechanisms underlying hypercalcemia-induced NDI are not well understood." https://www.kidney-international.org/article/S0085-2538(16)30704-9/fulltext +  
dulxy071  Why can't the correct answer be C) which points towards renal failure, which may lead to secondary hyperparathyroidism having the same results I believe +1  
pmofmalasia  The secondary hyperparathyroidism in renal failure is due to loss of calcium in the non-functioning kidney. In this question the calcium was elevated, so you can rule out renal failure. +