NBME Answers : drjo's page

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+1 visit this page (nbme19#35)

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no family history of neoplasia and unilateral neoplasm suggests sporadic form of retinoblastoma (vs germline (familial) form which is associated with bilateral retinoblastoma and osteosarcoma

in the sporadic form mutation occurs at the site (retinal cells) vs germline (familial) form mutation occurs in germ cells

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chaosawaits Correct me if I'm wrong but isn't C "somatic cells of the child" also correct? +

pakimd it is but it is not specific. it could mean any somatic cell of the body of the child and can therefore affect other parts of the body. +

+3 visit this page (nbme16#30)

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This (late bee sting rxn) is describing an Arthus reaction (localized Type III HSR) + IgG immune complexes accumulate at site --> mast cell degranulation --> Neutrophil recruitment + IgG immune complexes also stimulate macrophages to release inflammatory cytokines (IL-1, IL-6, TNF-a) and chemokines (IL-8) --> Neutrophil recruitment result in edematous indurated lesion

Timeline for arthus reaction bee sting: 1-8 hours, generally: 6-12 hours vs Late phase Type 1 HSR 2-4 hours

https://www.sciencedirect.com/topics/immunology-and-microbiology/arthus-reaction

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submitted by ergogenic22(401), visit this page

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Cool and pale extremities rules out distributive causes (neurogenic, anaphylaxis, septic).

Hypovolemic would describe a process of volume loss (bleeding or dehydration) and would not explain the crackles or jugular vein distension.

don't be thrown off by the normal heart sounds.

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baja_blast Raise your hand if you were also thrown off by the normal heart sounds. +11

jmd2020 I think this question is poorly constructed. Cardiogenic shock would result in an INCREASE in SVR - this woman's BP is 70/40... +3

drdoom @jmd2020 low BP does not mean the SVR isn't increased — it /is/ increased! it's just that the heart is so effed up that even massively increased SVR is not enough to maintain good pressure +4

drdoom another way to explain: imagine you are losing blood volume at a constant rate (someone punched a tube into your aorta and draining you like a pig); at first, your heart would beat stronger (ionotropy) and faster (chronotropy) to maintain BP; at the same time, all your arterioles would constrict to maintain blood flow rates (and perfusion) to vital tissues ... but at some point you will have lost so much blood that all the ionotropy, chronotropy & SVR in the world could not save you or your BP .. your BP will plummet no matter what compensatory mechanisms your body has up its sleeve. +7

drjo Jugular venous distension clued me into cardiogenic shock (heart isn't pumping well resulting in back up) vs the others listed, esp since obstructive shock isn't an answer choice +

kavarthapuanusha Crackles gave me the clue +

submitted by skuutnasty(8), visit this page

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after rabbit-holing this one for a bit.... this is the photo that demonstrates it best (to me, anyway). must be ilioinguinal n.

enjoy

https://d1yboe6750e2cu.cloudfront.net/i/5e43dd40330f1cd702313cf56b29b8b3f793b00b

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drjo Ilioinguinal n. derived from L1 is mostly sensory supplying skin of upper and medial thigh root of penis & upper scrotum (males) **mons pubis & labia majora (females) it accompanies spermatic cord through superficial inguinal ring, great pic of this ^ @skuutnasty +

ankigravity Why is this not at the top.. It's the best image by far. +

submitted by ootscoot(34), visit this page

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This guy has a normocytic anemia with evidence of kidney damage (increased Cr). According to UW, CKD can be assumed in a patient with high Cr and uncontrolled hypertension (which is evident in this dude that hasn't been to the doctor in years and has a 150/98 BP).

Also straight from UW: CKD is commonly associated with normocytic anemia 2/2 reduced production of EPO by the kidneys. Therefore, the most appropriate therapy is erythropoietin.

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dhkahat how do we know when to transfuse? +2

destinyschild I also thought about transfusing, but then thought that might cause iron overload since he's also getting iron supplements. I'm not sure if iron overload is a possibility w EPO. Please correct me if I am wrong +

drjo Transfusion is only indicated when hemoglobin is < 7g/dL & this tx is usually reserved for critically ill patients +5

submitted by drdoom(1206), visit this page

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Inability to maintain an erection = erectile dysfunction. So now the question is "Why?"

Fatigue, difficulty sleeping, difficulty concentrating is starting to sound like depression. "Difficulty concentrating" might be interpreted as impaired executive function or the beginnings of vascular-related dementia (dementia related to small but numerous cerebral infarcts), but on Step 1 dementia will be blatant (i.e., "lost his way home," "wandering," etc.).

Depression is actually common after a debilitating event like stroke, as you might expect. With depression comes a loss of sexual interest and desire—that is decreased libido.

One can make the argument that a "vascular patient" might have some issues with his "pipes" (arteriosclerosis, parasympathetic/sympathetic dysfunction) and, for this reason, nocturnal erection should be decreased; but note that nothing is mentioned about long-standing vascular disease (no hx of hypertension).

As a result, the best answer choice here is C. (Libido decreased but nocturnal erections normal.) The big question I have is, how the heck does this guy know he's hard when he's asleep!!? :p

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cbay0509 thank you +1

ilikedmyfirstusername there are several UWorld questions about psychogenic ED with the answer being normal libido and normal nocturnal erections, idgi +15

djeffs1 Yeah NBME says its C, but I still think with a recent stroke you can't bank on normal nocturnal erections... +

drdoom @djeffs nocturnal erections happen at the level of the spinal cord (S2–S4)! a “brain stroke” (UMN damage or “cortical damage”) would not kill your ability to have nocturnal erections! https://en.wikipedia.org/wiki/Nocturnal_penile_tumescence#Mechanism +2

drjo fatigue, difficulty sleeping and concentrating could be depression or hypothyroidism both of which can cause decreased libido +

jurrutia @djeffs1 when you say NBME say's it's C, how do you know that's the official answer? Did NBME post the answers somewhere? +

djeffs1 in the versions I purchased from them they highlight the correct answer in the test review +1

shieldmaiden For me the keyword in the stem is "maintain"; he can maintain an erection, therefore nocturnal erections must be normal. Libido, on the other hand, is psychologically driven, so if he is depressed (trouble sleeping, concentrating, fatigue, recent major health problem) then the strength towards any kind of desire, including sexual, will be low +2

chaosawaits His nocturnal erections are normal because his spinal cord is not damaged. His libido has decreased because he's showing signs of depression. +