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 +1  (nbme22#15)

Could also use the patient's age to make the differential. Age is a risk factor related to breast cancer (common in post-menopausal women, unless there's a history of breast cancer in the family).

Fibrocystic changes and fibroadenomas are usually common in premenopausal women.

No discharge noted, so it's not an intraductal papilloma.

yotsubato  Intraductal papillomas are also under the areola

 +6  (nbme23#4)

The question stem is describing a mitochondrial disease, which commonly present with lactic acidosis. There is an increase in anaerobic forms of energy production (glycolysis). The mitochondria are faulty, so they can’t use the end product of glycolysis (pyruvate) in TCA. Instead pyruvate is shunted over and is used by LDH (lactate dehydrogenase) to generate pyruvate.

Aside: Recall that LDH uses NADH and generates NAD+. Deficiency of LDH can lead to loss of regeneration of NAD+ and inhibits glycolysis.

drdoom  ... pyruvate is shunted over and is used by LDH (lactate dehydrogenase) to generate lactate*.
chris07  It's hinted in the answer, but I would like to clarify: max O2 consumption is decreased because O2 is consumed in the Electron Transport Chain, which occurs in the mitochondria. With the mitochondria not working, the ETC cannot work, and thus there is less demand for Oxygen.
masonkingcobra  Mitochondria are the powerhouse of the cell
uslme123  Apparently ragged red fibers are the result of coarse subsarcolemmal or intermyofibrillar mitochondrial accumulations.. https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/mitochondrial-myopathy

 +4  (nbme23#13)

This is representative of leukoplakia, a pre-cancerous lesion of squamous cells. In order for it to spread to distant sites, it must first invade through the basement membrane/submucosa. Could be confused with oral hairy leukoplakia (which also is a white patch that classically arises on the lateral tongue). However, oral hairy leukoplakia is not pre-cancerous and is often associated with EBV infections or people that are severely immunocompromised.

hpkrazydesi  How did you know that this wasnt oral hairy leukoplakia? just from the picture?
nwinkelmann  To piggyback off of @hpkrazydesi, you ruled out oral hairy leukoplakia because the patient was seeing the doctor for normal health maintenance, i.e. not immunocompromised, I'm assuming.
dentist  @nwinkelmann thats correct! my time to shine.

 +6  (nbme23#34)

Seeing fat in the stool would clue you in to whether or not the treatment regimen is working. Supplementing with pancreatic enzymes means that you should NOT see for fat in the stool.

Subcomments ...

submitted by mcl(377),

Since you're losing all your bicarb into your pee, you would expect the pH to be more alkaline. Also, since there is decreased Na+/H+ antiport, there is less sodium reabsorbed and therefore increased loss of free fluid to the urine.

mcl  useful figure http://users.atw.hu/blp6/BLP6/HTML/common/M9780323045827-036-f002.jpg +1  
joker4eva76  Why wouldn't this be similar to a Type 2 RTA where urinary pH <5.5? +1  
mcl  I can't remember exactly what the question was asking off the top of my head, I think it was asking about relative to normal? But I think you're right in that the alpha intercalated cells (AIC) can still dump H+ into the urine and acidify it to an extent. And, like in RTA2, I don't know that the action of the AIC would be able to overcome the bicarb and acidify the urine enough for it to be the usual pH, so the urine should still be more alkaline compared to baseline. Kinda sucks, pH less than 5.5 should technically be acidic but it's alkaline for pee. +  
mcl  JK, normal urine pH is around 4-8, but I guess they consider closer to 5.5 on the more alkaline side...? I guess I would go more off that the alpha intercalated cells can't completely compensate for the amount of bicarb in the pee due to the CA inhibitor, not so much the actual pH. +  
meningitis  Anhydrase inhibitors also affect the anhydrase inhibitors that are used in the AIC in order to excrete the H+. Here is a link:**http://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/distal_0.png** +3  
mcl  ohhhhhhhhhhhhhhhhhhhhhhh my god duh yes thank you <3 +1  
meningitis  Lol yw!! +