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NBME 24 Answers

nbme24/Block 4/Question#3 (reveal difficulty score)
A 23-year-old woman is brought to the ...
Renal tubular acidosis πŸ” / πŸ“Ί / 🌳

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submitted by magrufnis(0),
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m’I fconudse uaotb tish .eno kaWneess of nexnostei dan nornitpoa fo het rgith raefr,mo hwit a aeredesdc etprics sumcel tcehrst xefrle. ehT nsaerw wsa C7 nerve orot, ubt woh are ouy aebl ot ailezolc ot C7 dna ont 6C or C?8 I riufedg ttha xsotieenn is l,riaad C5T,-1 nad ponrniota si d,nemia lsao -5.CT1 seTrpci elxrfe is 7C-C8 9A1(02F ysas )6.-CC7 owH wolud oyu ornwra nowd to tjsu 7C e?damga

submitted by βˆ—brethren_md(100),
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eqiuRres oinkgwn hwo to uccatlale an niaon pga - okol ti pu. nI isht easc, it is a olmanr iaonn gpa etlibcamo is.diacso Kwon eht emnnumscio UIEMSPDL dan ASD.SARH lRena Tarlbuu csdiiaos si the lyno swnrea chocei atth si an elmeapx of a aonmlr noina tmcbloaie saoi.isdc

mousie  Anion Gap: Na - (Cl + HCO3) = normally around 10-12 +4  
seagull  good to know. I keep looking up the urine values but all it said was "varies", then I threw my computer and yelled "does that vary Mother F****ers. I do feel better now. +75  
_yeetmasterflex  glad I wasn't the only one who got very pissed off at the urine values +4  
fulminant_life  Usually the first thing I look at is whether or not the Cl- is high. Generally if the Cl- is high its going to be a normal gap +8  
henoch schonlein  i think they gave you the urine values bc you can calculate the URINE anion gap which is (Na + K - Cl). In this case the Urine Anion Gap is positive (5). Boards and Beyond mentions that a positive UAG is due to Renal Tubular Acidosis Type 1 (inability of alpha intercalated cells to secrete hydrogen ions). just another approach to answer this q +20  
270onstep1  Actually diarrhea is the "D" in "HARDASS"(reason why I was stuck between Chron's and RTA). Ended up getting it right with RTA.. +1  
talha_s  So the reason this is not Crohn's disease is actually what BnB explains in Renal Tubular acidosis video. Anytime there is a Metabolic Acidosis with intact kidney secretion of H+, the URINARY Anion gap (Na+K-Cl) is NEGATIVE. This is because the excess NH4 that is secreted into urine is combined with Cl-. Therefore, in Crohn's disease and Type 2 Renal Tubular Acidosis, the urinary anion gap is NEGATIVE. In this question, the urinary anion gap is POSITIVE so this would be an example of Type 1 RTA because the kidney can not excrete H+. I got it right by chance, definitely did not understand it in this much detail when I was answering it lol +9  
ih8payingfordis  FA 2019 pg 580 - 581 +  

submitted by βˆ—abhishek021196(91),
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Unier noian gpa = irneU Na + K βˆ’ Cl

nI a bimetlcoa aoisscid iwttuho a smrue nanio ag:p

A pvisoeit neriu niaon pag ssgtgesu a olw ruaryni NH4+ .eg.( rnlea rultuba s)

A evgtiena enuir nanoi agp ssggsteu a hihg rurinay 4H+N .(eg. hri)rad.ea

submitted by yobo13(5),
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Can nsoeoem xaplien wyh ti t'anc eb 'sohCnr sienc tath woudl oals asceu a nno GM?AA

drpatinoire  If she has Crohn, she has already lost a lot of K, HCO3-, then the compensatory system wouldn't let her keep losing electrolytes in her urine. +1  

submitted by βˆ—medguru2295(56),
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uYo ddint' lylaer edne ot caaultlec nniAo .gpa Teh bcaibr aws XALEIOELCPTYN lwo. Taht si eynlragle A.TR iAltalyin,odd eth Cl wsa vyer hghi in hte ittgens fo thero oalnmr ollnad,iydiA.t ti wsa a s wlo tsoen orev( 2 wse)ke kcnigokn otu anmy ehrot iseohcc teall,aScyi( cLtcia sdsic,Aoi ,ADK dan ollcohAic otaoeK.)iscids

submitted by βˆ—cocoxaurus(59),
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UBT ywh is the surme ipmtaouss lomanr?

I aws aelb ot rornwa ti wdno to T,RA bcuaese oenn of hte thoer easnrw eoihscc eadm chmu snsee, but eth tsaipsumo had me csnedo ungesigs fey.lsm naC emesnoo laeinpx tath lba finn?igd sTkanh!

subclaviansteele  My take is that hes not super acidotic and the K is at the low end. +  
nwinkelmann  see the comment by @zbird, which explains that the urine anion gap is important (which I took to interpret as more important than the serum K+ level, lol, because the normal K threw me off too). +  

submitted by zbird(2),
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hsiT tiaetpn sha ysaTeilp-Dt I RAT cihhw is deexnilap by olmNra rSemu iAnno apg 8() lctobieaM ssicoiad wtih ehr ospeitiv ryainur annio 5+a(gp.)

krewfoo99  Why would the urine Potassium be so high if it is type 1 ? Shouldnt it be type 2? +  
drpatinoire  @krewfoo99 I think it's RTA2 (Fanconi syndrome), he is losing all kinds of Na, K, Cl which should be reabsorbed in PCT. +  
misterdoctor69  @Drpatinoire: it can't be RTA2 because the urine anion gap (UAG) is positive (+), which implies that the patient is unable to secrete H+ (via NH4+, which couples w/ Cl-). RTA2 on the other hand has a negative (-) UAG because RTA2 affects only the proximal tubule's ability to reabsorb bicarbonate (i.e. H+ secretion via NH4+ in the distal convoluted tubule is unaffected). +  

submitted by βˆ—sherry(35),
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Dearahri ni ADSASRH anc ldae ot mblaotice soscidia sa ll.ew nO secodn gtuohht I cdiddee to teak chnro ediseas uzc I ufgdrei teh ciclainl irpectu si rome tetettnirmni wiht upomiasts id.arsnuestcb I suseg I utsj virehtnok ued ot eht kcla of hrtoe ilhapcsy rneam.solibait

daddyyikes  other than the patient not haveing any sxs of crohn's i dont see any reason why its not crohn's. we differ crohn's and rta by urine anion gap. in chronic diarrhoea it is negative while in rta its +ve but in question the anion gap was normal +  

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