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Welcome to taediggity’s page.
Contributor score: 30

Comments ...

 +4  (nbme22#2)

So this patient is essentially in hypovolemic shock because he's hemorrhaging blood from the aorta.

A) You'd have increased ADH to conserve volume B) You'd have increased BUN:Cr ratio b/c due to a decrease in blood flow C) Increased TPR naturally due to less pressure on barorecptors D) Decreased Capillary hydrostatic pressure b/c they have decreased volume E) Decreased Carotid sinus firing rate b/c less pressure F) The Answer: RAAS is activated -

drzed  (B) You get an increased BUN:Cr ratio because increased urea absorption at the proximal tubule (conservation of water), but you lose the same amount of Cr since none of it is reabsorbed; thus the ratio increases. +5
kevin  I may be wrong but I think more of the urea (BUN) would be absorbed in medullary collecting duct in this situation due to ADH; think I saw a question on this in uworld, could pop up +

 +2  (nbme22#31)

2/6 systolic murmur over the left sternal border,an S3 (increased LV filling), low 02 sat, figured this patient had hypertrophic cardiomyopathy and early signs of CHF, so the answer was crackles from the pulmonary edema from fluid back up from the HF as brise pointed out below the 1st comment.

samadmom  I believe this patient actually has dilated cardiomyopathy (as opposed to hypertrophic) due to his age, HTN, presence of S3 (hypertrophic usually has S4), and also his murmur. The murmur indicates mitral regurg, the tip-off was "radiating to the axilla". Because the stem states that the PMI is diffuse this can lead us to think that his heart has enlarged in an unpredictable way (ie. making it acceptable that the placement of the murmur is different from where we expect). Lastly, secondary mitral regurg is an indicator of poor prognosis for HF. Once the ventricle has dilated to such a point, the mitral leaflets are unable to properly close and perpetuate the backward flow of blood. Hope this helps! +

Subcomments ...

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nramuesboM Grelslriepmniuotho si toprich;eN NLOY IRINREATPUO si in hte negttiev

It t'nac be NPGM eaceusb NPMG is erNitcphi hitw olbespis htoirpeNc

rteOh hciesoc are mileetiadn by Rnlae psioyB

hungrybox  agreed "granular deposits" rules out MCD (the only other nephrotic syndrome) because MCD is IF (-) +4  
cooldudeboy1  could someone explain why the other choices are ruled out by biopsy? +  
arlenieeweenie  @cooldudeboy1 PSGN does have a granular immunofluorescence, but there is no previous illness or hematuria mentioned so you can rule that out. Goodpasture is classically linear IF since they're antibodies against the GBM. IgA nephropathy is mesangial IF so it would deposit more in the middle. Minimal change wouldn't show anything on IF +2  
qball  I know First Aid states MPGN as a nephritic disease but I think it can present as nephritic or nephrotic syndrome. Of course, the renal biopsy helps give it away but I wouldn't be so quick as to rule out MPGN +1  
taediggity  Totally agree w/ you Qball... I thought MPGN too, but I think Penicillamine makes it Membranous Nephropathy +  

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Not 0%10 eusr no shti ,oen tub rs’ehe who I cpraohpade ti: eiinstmha aucess rtalaire idiaolnt da(de=cseer orlatrirea ),csteisanre tub lla of ttha olobd ash ot og weoremhes ncise uoy wno eahv moer dbolo gilnowf hutghro hte sraietre dan ttah ehemwrose is the lipcaiaerls rasci(need aalpyilrc htyrcaodtis srerp)su.e aeisHnmit sucsea srecianed eatrilieymbp fo the atolclypr-aips selunve n(eo of .rD aSttsra’ ifrtveoa tf)asc so duy’o eahv rnieescad pacrilayl ifltinrtoa aer.t

taediggity  Totally agree, arterial dilation--> increases blood flow into capillaries/increases capillary hydrostatic pressure + increasing permeability of the post-capillary venules= Increased Capillary Filtration Rate +1  
makinallkindzofgainz  I love you explanation, but I don't think filtration rate is dependent upon permeability of the post-capillary venules. I think the filtration rate is increased simply due to the increased blood flow; this is similar to how increased renal blood flow will increase Glomerular Filtration Rate (GFR). +10  

submitted by drdoom(819),
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uoY vaeh to hknit tobau this sugin eht conepct of ATNLIDONIOC TRPLB.AIOIBY hAnoert ywa to ksa sthi pety fo oiqnstue si iekl hi:ts “I hows ouy a nepitta htiw nnpsasuotoe paut.eorhmoxn chihW oreth ginht si tmso iellky to be ture uotba htat rp”?neso rO oyu can hasper ti eseth yw:as

  • Geinv a INTIOCNDO (aoeusptnsno puonme,) athw roeth gidnfni si tsom llykei to be het es?ca
  • vneGi a pool of lpoeep hwti sopuaeotnns ,athroepumnox hwta hotre tnhig is somt lyekli ot eb utre atbuo et?mh

In ohert dsorw, of lal eolpep hwo den pu ihwt susanentoop eum,opn the tmos nomomc oerht gtinh tobua tmeh si thta etyh ear ALEM ;map& .ITNH

fI I agve oyu a ekcutb fo suoapetsnno poumen atpeisnt -- adn you erechda royu nhda in ehret nda lupdel eno uot -- hatw icenraos owuld be ermo n:mmcoo In rouy dahn you veha a esrkmo ro in yuor nahd ouy aehv a thin l?aem Ist’ het tlr.aet

someduck3  Is this the best approach to all of the "strongest predisposing risk factor" type questions? +  
drdoom  There is a town of 1,000 men. Nine hundred of them work as lawyers. The other 100 are engineers. Tom is from this town. He rides his bike to work. In his free time, he likes solving math puzzles. He built his own computer. What is Tom's occupation most likely to be? Answer: Tom is most likely to be a lawyer! Don't let assumptions distract you from the overwhelming force of sheer probability! "Given that Tom is from this town, his most likely occupation (from the available data) = lawyer." +4  
drdoom  There is a town of 1,000 spontaneous pneumo patients. Six hundred are tall, thin and male. The other 400 are something else. Two hundred of the 1,000 smoke cigarettes. The other 800 do not. What risk factor is most strongly associated with spontaneous pneumo? (Answer: Not being a smoker! ... because out of 1,000 people, the most common trait is NOT smoking [800 members].) +4  
impostersyndromel1000  this is WILD! thanks guy +3  
belleng  beautiful! also, i think about odds ratio vs. relative risk...odds ratio is retrospective of case-control studies to find risk factor or exposure that correlates with grater ratio of disease. relative risk is an estimation of incidence in the future when looking at different cohort studies. +  
drdoom  @impostersyndrome I love me some probability and statistics. Glad my rant was useful :P +  
hyperfukus  @drdoom i hate it which is why your rant was extremely useful lol i learned a ton thanks dr.doom! +1  
dubywow  I caught he was thin. The only reason I didn't pick Gender and body habitus is because he was not overly tall (5'10"). I talked myself out of it because I thought the body habitus was too "normal" because he was not both thin AND tall. Got to keep telling myself to not think too hard on these. Thanks for the explanation. +1  
taediggity  It isn't just that this person has Ehlers Danlos and they're more prone to spontaneous pneumo??? +1  

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luoAghht ehrte rae on ecicpisf hespre r,iidotcnas a FCS lpaen iwth osmtyl eyolskteuc andeistci a rvali tcoinfnie (as lwel sa teh almnor cso.)gleu So you can rleu tuo T,B ducieorsrasnioos nad tlieaba.rc iresniki/rndzkguB sgni rae etrldea to innm,igitse ubt eenv if uyo otn'd ownk twah thseo era, het quoensti says ttha teehr is na namibyrotla ni hte MLEOTPAR bleo netniismig( = m.geinn)es paclsetnhiEi uwlod be hte setb ,wnraes selypelcai becasue spereH iEiaphntlesc sfectfa teh reapomtl lb.oe

taediggity  Also look for Kluver-Bucy like symptoms in the stem +1  
mambaforstep  why? +  
b1ackcoffee  I agree with everything but normal glucose. Glucose here is NOT normal. to quote wiki "The glucose level in CSF is proportional to the blood glucose level and corresponds to 60-70% of the concentration in blood. Therefore, normal CSF glucose levels lie between 2.5 and 4.4 mmol/L (45–80 mg/dL)." +  
baja_blast  NBME reference table gives normal CSF glucose to be 40-70 mg/dL. As far as I'm concerned, for the purposes of the exam the reference table is probably a better source than wiki. +4  

submitted by seagull(1443),
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uot fo iyousc,rit owh mya eelppo nekw ?itsh otdn( eb syh to ays uyo ddi ro d?tni)d

My erpotyv ctdoaienu ddni't aniigrn hist in em.

johnthurtjr  I did not +1  
nlkrueger  i did not lol +  
ht3  you're definitely not alone lol +  
yotsubato  no idea +  
yotsubato  And its not in FA, so fuck it IMO +1  
niboonsh  i didnt +  
imnotarobotbut  Nope +  
epr94  did not +  
link981  I guessed it because the names sounded similar :D +14  
d_holles  i did not +  
yb_26  I also guessed because both words start with "glu"))) +27  
impostersyndromel1000  same as person above me. also bc arginine carbamoyl phosphate and nag are all related through urea cycle. +1  
jaxx  Not a clue. This was so random. +  
ls3076  no way +  
hyperfukus  no clue +  
mkreamy  this made me feel a lot better. also, no fucking clue +1  
amirmullick3  My immediate thought after reading this was "why would i know this and how does this make me a better doctor?" +7  
mrglass  Generally speaking Glutamine is often used to aminate things. Think brain nitrogen metabolism. You know that F-6-P isn't an amine, and that Glucosamine is, so Glutamine isn't an unrealistic guess. +4  
djtallahassee  yea, I mature 30k anki cards to see this bs +4  
taediggity  I literally shouted wtf in quiet library at this question. +1  
bend_nbme_over  Lol def didn't know it. Looks like I'm not going to be a competent doctor because I don't know the hexosamine pathway lol +21  
drschmoctor  Is it biochemistry? Then I do not know it. +4  
snoochi95  hell no brother +  
roro17  I didn’t +  
bodanese  I did not +  
hatethisshit  nope +  
jesusisking  I Ctrl+F'd glucosamine in FA and it's not even there lol +  
batmane  i definitely guessed, for some reason got it down to arginine and glutamine +1  
waterloo  Nope. +  
monique  I did not +  
issamd1221  didnt +  
baja_blast  Narrowed it down to Arginine and Glutamine figuring the Nitrogen would have to come from one of these two but of course I picked the wrong one. Classic. +1  
amy  +1 no idea! +  
mumenrider4ever  Had no idea what glucosamine was +  
feeeeeever  Ahhh yes the classic Glucosamine from fructose 6-phosphate question....Missed this question harder than the Misoprostol missed swing +1  
surfacegomd  no clue +  
schep  no idea. i could only safely eliminate carbamoyl phosphate because that's urea cycle +  
kernicteruscandycorn  NOPE! +  
chediakhigashi  nurp +  
kidokick  just adding in to say, nope. +  
flvent2120  Lol I didn't either. I think this is just critical thinking though. The amine has to come from somewhere. Glutamine/glutamate is known to transfer amines at the least +1  

submitted by nwinkelmann(285),
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I nufod shti newh nriytg to nrtnsdadeu hwy risaenecd NO cudsae ceahh:sade sinrist/tetetirNa rea a yrev cnmmoo chhaedea adn eaiirgmn food grtiresg e)DW(bM nda rieas ntciir xdieo Hgih vllese fo ritinc eiodx aer tdsaaoiesc hitw eaimnrig )yd(Sut. caeeshHad nad seagiinrm rae olsa yrve coommn ni icnatdeioms atht stoob inrict ix,oed chus a argavi (tdyus), but it is ecalurn yhw tish nhas.pep eTh iglinrao tisyheposh aws that incitr exodi ceraesnsi bodlo evessl ezis nda sggirret a em,naigir tub eht vigaar tudsy adn eshrot dipsevodr ths.i eeNwr tssdieu on rciitn eoxid shosw ttah it eesnisrac the pepdite ()PCGR ttah is icondereds lepibsesnor for gitgingrer irgnamsie Syu)td( tefar sresniaec in i.ilanofmatnm sueaBec crntii dexoi si oaiecsdsta ugioenenrc imnanaloftmi es,edssai 'tsi kyiell ttha dshehaeac adn iamrneigs fmor tnciri doexi ear a inwnarg ngsi fo tsih fiolmtnaanmi S).tdu(y

hTe cerashre si yaabcilsl itgatns hatt itnserat esiar rictin xdoei lveesl adn hgih intrci ieodx eslvle eienarsc ilamofatninm adn shhcaedae dan Hove,erw het tcxae nrsoea hyw stih hpnpaes is o.uwnknn


taediggity  Goljan and FA mentioned this as Monday Disease for people who worked in industries that heavily used nitrates, where they would build tolerance during the week and then get a headache when they went back to work on Monday +3  
nootnootpenguinn  Just to add to this- one of the side effect of NG when given to patients with MI is "massive headache"! That's how I the question right! +  
mumenrider4ever  This is similar in how triptans induce vasoconstriction which is used to treat migraines +  

submitted by welpdedelp(219),
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It wsa a igFerruusno -toi;g-sed&b sotiss.beas oesrgrFuinu ieobds ear eibvdele ot eb defrom by gmaaorhepsc htat aveh aoshycgdpoet nda edaemtttp to itgdse eth .rebsfi

almondbreeze  info about ferruginous bodies being mf can't be found on FA/UW :'( they just say it's 'material' +  
taediggity  FA 2020 677, FA 2019 659... mf?? mofos?? +3  
69_nbme_420  Just to add: The question asks what cell type initiated the Fibrosis → Alveolar macrophages engulf the particles and induce fibrosis (same pathophys for all Pneumoconiosis). Pathoma 2019 Pg 92 +7  

submitted by mattnatomy(41),
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Sveeer eetyrpohnins eotfn lades to slphrpceitya rrslaoeirseootclis non-isoni(k .aeap)ncearp lsAo ees oopfrrtainlei fo tsomho ecumsl l.selc

meningitis  and explains the flame hemorrhages (Goljan) caused by malignant HTN +5  
taediggity  FA 2020 pg. 537 +  
dentist  FA 2020 pg 301* +  
ally123  The flame hemmorhages are also a good buzz word for recognizing he has hypertensive retinopathy 2e chronic, uncontrolled HTN. Pt's with hypertensive retinopathy can also present with "cotton wool spots" and "macular star". Pics on FA 2019, p. 299 +2  
surfacegomd  Pathoma (2018) p. 69 +  

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sThi neo aws a llttie tyicrk. oFr isth oen the yke si het olw rdnieaoioid p.etkau sTih teinatp sha ghih 4T and lwo SHT chihw kesam nesse in a pyyrdtehhior nteiat,p rpeasph uyro srtif ttuhgoh is htat tish ietpnat has esvGar’ aie.sdes eovwe,rH ni ve’sarG ryou hiydort si bineg dstlaeimut to emak eorm trohyid nohemro fmor achtrcs nda as ucsh odlwu vahe an sacreeidn erdooiaiidn pkueat ceebsua eht hrydiot si iiggbnnr ni hte urderqie n(wo dibrolaa)dlee nieo.di sihT si wyh ti is ont evaGsr “eserela( of rytidoh orhomen mrof a todriyh asmilutdte by ni.”dieo)tbas

oS if tsi ont r’Gasev thwa oculd it ?eb oFr ihst ’ydou veah ot owkn atth oH’ohamstsi dtihoiysriT saol( noknw sa crnihCo hmtcoiypLyc hTiosryditi nad is ftone rreeferd to as csuh on darob semxa ot torwh you ffo) ahs rethe phasse - fsrit yeth rae hhdop,rtriyey ethn yoe,rihdtu ethn teh sisaccl hopdityryoh ttha uyo lwudo exptec hwti wlo T4 adn hgih T.HS hiTs swa the eyk to htis s.iuqtneo ehT seorna orf hsit is ttha iaydihtotnr rioeapdsxe otbdiaesni ni asosHt’imoh eusca het otirydh ot srleeae lal fo sit tdesor ityodrh honmroe ikngma the neittpa yydrhhiprtoe fro a sohrt odeipr of iem.t frteA sthi vissaem ereelas fo hdotyri oonrh,em het biditoanes kema tmhe aenlbu to amek new TH dna foeeterhr etyh ceoemb ytruhoeid ofr a othsr dreopi nad neht oripyhhdoty whhic uoy louwd epcex!t eciSn yeht n’tca amke enw TH, eth toyirdh llwi ont teka up hte rodoaiindie adn toeeherrf erhte lwli eb low roinoieiadd apke.tu ncHee, s“elraee fo sdtore irthyod nehromo morf a yrhdoti dgaln tltedfiarni by mopel”yhc.tsy aak Lctypoh“iycm ssh)thoim(ao tiothiisrdy”.

I ihnkt alesr“ee of iyrtdoh rohemon orfm a aslmmhoyoptu otrhdyi nldg”a si gienerfrr ot emos nidk fo htrdoiy cnaerc ni hwchi acse uoy luodw xecetp thme ot be gndirbesic a uelnod no eddanoiiiro tk.paeu

yamr​uSm ovedi hree adn saol a arteg tsie in :aglerne oimddeorhsyacd/ernpeinriuapceq//ron/shtot.://elntegdi

aesalmon  pg 338 of FA lists it under hypothyroidism but it does present as transient hyperthyroidism first +9  
hyperfukus  yep that was the key! Goiter is "HOT" but the remaining answer choices were still kind of bleh D was distracting the hell out of me i spent so long to convince myself to pick C and move on +3  
hello  Pasting nwinkelmann's comment as an addition: Choice "D" is wrong b/c "lymphomatous thyroid gland" = primary thyroid lymphoma (typically NHL, which is very rare) or Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. Both of these present with hypothyroidism with low T4 and high TSH (opposite of this patient). +1  
taediggity  I absolutely love your @liverdietrying, however the pathogenesis of postpartum thyroiditis is similar to Hashimoto's, so I think this person has postpartum thyroiditis and your explanation of transient thyrotoxicosis is spot on, which would also occur in postpartum thyroiditis +9  
pg32  I agree with @taediggity. Also note that women eventually recover from postpartum thyroiditis and typically become euthyroid again, which doesn't happen with Hashimoto's. +  
vulcania  In FA (2019 p. 338) it says that thyroid is usually normal size in postpartum thyroiditis, but the patient in this question had a thyroid "twice the normal size." I guess at the end of the day it doesn't matter which diagnosis is right for this question cause they both seem to lead to the same correct answer :) +2  

submitted by dr.xx(144),
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As rtpa fo ciynreobm mdl,vepneeto eth crasepna osmfr sa wot udsb from the to,grefu an cbomyrein buet atth si a urpesorcr to hte gtnsoaaltsritnei ra.ttc It si ertofhree of menldaorde ionrg.i


gh889  nice! I reasoned it as that most of the GI system is of endodermal origin +9  
taediggity  FA 2020 pg 613 +1  
mutteringly  FA 2019 pg 599 +  

submitted by bubbles(67),
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menastBe reeammbn ntgeyirit si het remdneitnta of ulfl gnul eyevorrc ofgllowni mopnuaryl ui.tnls


1)( slso fo nsbmaete nmmerbea gyetitnir is aclirict ni rndeentimgi eth tin“op fo on n”,erurt dna itsctuboenr to eth iiabnylti ot beehtsralsi aomrln ungl acehutctreir thwi ptmoonoir fo fsis;iorb

)(2 sslo fo eiiltpahle ,lsecl olihlendeat ce,lls and smebenat abnmerem teiytginr ni lsuua iisirttlnaet npunoaeim eadsasoitc ithw padtohiici louramnyp iobfsirs asdel to ertodsedy guln etuacrchetri adn lutrpeape is;ifosbr

3() ntrsfiomrnag gwrtoh ofc-tβra si se,cesanry but nto eentylri scni,uiffte ot eoomptr npteamrne iiosbfsr;

)(4 tnieestsrp inrt/tiryainnan/rtejgui is taicrlci fro eth gonpraaopti of sbisfiro;

)(5 dcopitahii ylraopunm oiissfbr si an maxeple of a rpcseso ledreat ot eht rtnsecpisee of an n,)stg”an“(ei ichnocr nfial,taonmmi nda s;oiifsbr and

6)( euqniu lecls rae iccartli ecllralu yrlaeps in hte gneiurtaol of srbf.oiis

ni :ctaoitm4c2.P./nl4Chs5ionnlaig1cM6ir/.pbst.:mtwpw/2c/vt//weh

kernicterusthefrog  Lovely +  
endochondral1  any FA or pathoma or uworld correlation? +  
endochondral1  or was this a random? +  
taediggity  Type II pneumocytes serve as the stem cell precursors, w/out those you're more or less fucked: FA 2020 pg 661 +4