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submitted by sattanki(71),
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eDos aenoyn eahv yna edai on htis ?tqeusino hhuTgot ti wsa A.SL

ankistruggles  I thought it was ALS too (and I think it still could be?) but my thought process was that a lower motor neuron lesion would be the more specific answer. +2  
sattanki  Yeah makes sense, just threw me off cause ALS is both lower and upper motor neuron problems. Corticospinal tract would have been a better answer if they described more upper motor neuron symptoms, but as you said, they only describe lower motor neuron symptoms. Thanks! +6  
mousie  Agree I thought ALS too but eliminated Peripheral nerves and LMN because I guess I thought they were the same thing ....??? Am I way off here or could someone maybe explain how they are different? Thanks! +1  
baconpies  peripheral nerves would include motor & sensory, whereas LMN would be just motor +15  
seagull  Also, a LMN damage wouldn't include both hand and LE unless it was somehow diffuse as in Guil-barre syndrome. It would likely be specific to part of a body. right??? +1  
charcot_bouchard  No. if it was a peri nerve it would be limited to a particular muscle or muscles. but since its lower motor neuron it is affecting more diffusely. Like u need to take down only few Lumbo sacral neuron to get lower extremity weakness. but if it was sciatic or CFN (peri nerve) it would be specific & symptom include Sensory. +1  
vulcania  I think it's ALS too. The correct answer choice here seems more based on specific wording: the answer choice "Corticospinal tract in the spinal cord" wouldn't explain the tongue symptoms, since tongue motor innervation doesn't involve the corticospinal tract or the spinal cord (it's corticobulbar tract). This is a situation of "BEST answer choice," not "only correct answer choice." +  


submitted by beeip(124),
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You can see the einadmforteeon uertscutr in isht raid.mag

lsmarshall  Rectal prolapse through posterior vagina ("rectocele"). https://www.drugs.com/cg/images/en2362586.jpg +8  
famylife  "When a rectocele becomes large, stool can become trapped within it, making it difficult to have a bowel movement or creating a sensation of incomplete evacuation. Symptoms are usually due to stool trapping, difficulty passing stool, and protrusion of the back of the vagina through the vaginal opening. During bowel movements, women with large, symptomatic rectoceles may describe the need to put their fingers into their vagina and push back toward the rectum to allow the stool to pass (“splinting”). Rectoceles are more common in women who have delivered children vaginally." https://www.fascrs.org/patients/disease-condition/pelvic-floor-dysfunction-expanded-version +16  
usmleuser007  really like the pubic hair.... +4  
nnp  why not spasm of external anal sphincter? +  
vulcania  After looking it up I think that external anal sphincter spasm would be more associated with rectal pain and maybe fecal incontinence. I chose the same answer because I figured if there was a problem with the rectovaginal septum it would have been noted on physical exam... +1  
ajss  I did the same, put sphincter spasm because I thought a rectocele would be found on a physical exam. +  
thisshouldbefree  this is the map ive been looking for +1  
mnunez187  I didn't choose spasm because the stem says there the rectal tone is normal +1  


submitted by shaydawn88(8),
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Is it n-eorravilltaa tdanssreatu uescbae ihst itetnpa tighm evah HF d/t .a bif nad telf laatir lneg-tre&atenmg; inc diothcysatr &rtpu;e-sergs atutdnears aplelru uns?fiefo

sajaqua1  Basically. +4  
medschul  Why can it not be arterial hypertension? +2  
meningitis  I think Arterial HTN is referring to Pulmonary Artery HTN which would be present in LT HF in the long run with RT HF and edema. Pulm HTN would cause a backflow, and doesn't really answer the question "explain the patients Dyspnea". At least, that's how I saw it. Hope this helped. +5  
sugaplum  the question has 2 murmurs, so does she have aortic stenosis too? i guess it is not relevant since it asked for what is causing her SOB +2  
nukie404  I guess pulmonary HTN would happen in response to increased pressure after the edema happens, and would cause backflow (to the RV) over pulmonary edema. +  
vulcania  There's a really great diagram in UWorld (QID 234) that explains what happens as a result of mitral stenosis. Very similar sounding to the patient in this question. +  
srdgreen123  @sugaplum, yes rheumatic heart disease can cause mitral and aortic stenosis. Rheumatic aortic stenosis can be distinguished from degenerative aortic stenosis by 1)coexisting mitral stenosis and 2)fusion of the commisures. +1  


submitted by axsa19(9),
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BA si het lnyo obdol orgup atth osed ont evah pereofmrd gIM aoibsendti ni het m.aalps

Blood purog A has ani-tB MIg

ldBoo rgpuo B ahs aniA- gMI

oodlB porgu BA DN"A"A

odoBl pugor O ash obth -Ainat ;am&p in-aBt MgI

FA 2107 paeg 039

axsa19  anti* +  
noname  FA 2018 page 400 +  
vulcania  FA 2019 p. 397 +1  
destinyschild  blood group O also has IgG, which is significant bc it can cross the placenta and cause hemolytic anemia in a fetus +1  


submitted by seagull(1539),
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Why si hist ont SHU? wHo did uyo guys prophcaa het qo?usinet

joonam  I think if this was HUS (d/t a bacterial infection) the leukocyte count would be abnormal (11k<) +  
yotsubato  normochromic normocytic RBC thats why. You would see schistocytes +9  
vulcania  Also for HUS I would expect mention of h/o bloody diarrhea, or at least diarrhea (not URI), and mention of something to do with kidney damage. +  


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hisT eon asw a tltlie .kryict orF shit one teh eky si eht wlo diaoriideon tae.upk isTh tetanip sha hihg 4T dna low TSH hhciw sakem sseen ni a rhodyyphirte atptine, eprsaph oyur fstri tuhohtg si atht tish apttnie ahs ar’evsG eed.aiss eorw,evH ni av’Gres oryu hyitdro is ngeib udlatsimte ot amek mero dhtyroi onrheom romf casrcth nad sa shuc lwduo evah an dcneerias donoriieiad uetpka abecesu eht tiydhro si nngibgir ni eht uerdireq wo(n a)deliaeodrlb oieni.d hisT si why it si otn aveGrs elaer“s(e of ytdhori oorhmen mrfo a rthdioy mdeiastult by eio.)idnsatb”

oS if its ton vrGse’a waht ludoc ti eb? Fro hsti uy’do ahev to wnko hatt hstoaiHs’mo dihToiiryts a(sol nnkwo as cCihnro cmLycthipyo ytsiohrTidi nad si enfto errrfeed ot sa ushc on droab aemxs ot rhwot you )off has teerh asseph - ftisr tyhe are ihht,yrpdroye hten udir,heoyt neht het ascscil idoohypytrh taht uoy udolw ptecxe ihwt olw T4 nad ghih .TSH ishT asw teh yek ot itsh eitq.ousn ehT esaorn rfo shit is ttha dtihnytaori xasdpreieo nbiedtioas in ia’tmoosHsh sacue hte iydroht to rleaees all of ist trodse dhritoy oorehmn amgkni hte neiatpt rhypoiheyrdt rof a hsort ieodrp of it.me retAf htis svmaesi lreaees of hyoridt nh,moore the baiiednsto keam hemt laneub to maek ewn HT nda ereoerhft they mbeoec odtheruiy fro a torhs roiepd adn nteh iprthdoyyho wihch ouy odulw tceep!x icSne thye ntc’a emak ewn ,TH eth hdortiy lwil not tkae pu the iioordeadin and oeertfher reteh liwl be owl dneraiidoio pt.keua ceHne, ase“elre fo tredos roitdyh rnohmoe ofmr a rhyotdi agdln idtatielnrf yb .e”octylhpyms kaa ycyhLt“moicp oma)to(isshh si”irt.hiydot

I inkht s“earele of hoitdry hnreoom ofmr a otmlhuysamop ythdior gdna”l si ergenfrri ot mseo dkin of rthdoiy ccraen in hhwci sace yuo duolw tecxpe mthe ot be bdsicenrgi a noduel no oidoarieidn .tuepka

m​mySaru devoi eehr dan also a etrag seit in arnl:eeg rnda/resnudrehqeoaltp:ocnetityghoc//d/poierd.//snmiei

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 +11  
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 step420(34),
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CGH-B and TLFS,SHHH, erhsa mase lphaa bun,isut os HCG nca caieatvt oesth ceorpetsr if sit ni gihh ngheou ttnay.uiq titAvicnag HL peretroc lilw dlae ot omre eestnoertTso ofmr het Ldiyge .lcesl oerM eresettoonst can dlea to meor egnterso iotmnoraf vai aaoets.mra

dickass  bHCG directly increases testicular aromatase activity, it's not because of the increased amount of testosterone. +5  
vulcania  And for those who were wondering (cause I was), Sertoli cells have aromatase (FA 2019 p. 614) +5  
godby  It's a slightly different question, on the stem, what's the purpose of the hCG to him, for infertility or increased sexual demand ? Just curious. +  


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I gto ti nowd to bolyncmie ap&m; cicmhrouabll dan netw wthi rlcuhcmaobli dos(nude elik ”su“nlfuba ... llo) beecasu I ugtthoh icbylmneo swa orf stteicraul ncsc/deoagkHrni ampohylm. I relat dnuof out thta lirmlhcobcau si cytualal a eefedrprr eteartnmt orf CL!L sI it eabceus mrcoalcbiulh seusac sevree ps?neiursommsipoun oS you ult’wnod be iggnvi ti ot a 27 oy amn in the sirft alpe?c

yotsubato  Bleomycin is the big boy of cancer treatment. I've never heard of chlorambucil and its not in FA. +1  
vulcania  I had never heard of chlorambucil either and after researching it found out that it's also an alkylating agent, specifically a nitrogen mustard - same as busulfan, so you weren't wrong! Based on what FA says re: bleomycin & busulfan (extrapolating this to chlorambucil), they both cause pulmonary fibrosis & skin hyperpigmentation, however, in the Lange Pharmacology flashcards it says that the hyperpigmentation with busulfan is from adrenal insufficiency so I guess you would expect to see symptoms of that as well if the same applies to chlorambucil? +1  
vulcania  jk ignore my previous comment. just checked uptodate and it doesn't list hyperpigmentation as a side effect of chlorambucil. +  


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I ogt it wdno ot cnbemyilo ma&;p macobluirhlc dan tnwe with ulmcbiolhcra noeus(dd like ub“s”flnua ... )oll beceaus I gotuhth ymliocbne aws ofr eiurstcalt i/gHdrnoaeknccs oaypmhl.m I ltare ufond uto that hiaubcomcllr si lytlcuaa a rerfedpre teartemnt rfo LC!L Is it aebuesc cubaomrclhil seusac esvree emsmsrpunouniios?p oS oyu wn’toudl be vnigig it ot a 72 oy anm in hte irtsf c?epal

yotsubato  Bleomycin is the big boy of cancer treatment. I've never heard of chlorambucil and its not in FA. +1  
vulcania  I had never heard of chlorambucil either and after researching it found out that it's also an alkylating agent, specifically a nitrogen mustard - same as busulfan, so you weren't wrong! Based on what FA says re: bleomycin & busulfan (extrapolating this to chlorambucil), they both cause pulmonary fibrosis & skin hyperpigmentation, however, in the Lange Pharmacology flashcards it says that the hyperpigmentation with busulfan is from adrenal insufficiency so I guess you would expect to see symptoms of that as well if the same applies to chlorambucil? +1  
vulcania  jk ignore my previous comment. just checked uptodate and it doesn't list hyperpigmentation as a side effect of chlorambucil. +