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Contributor score: 101


Comments ...

 +35  (nbme22#15)
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ihsT noe wsa a elttli ckyr.it oFr hsti oen het yke si hte lwo oionirdeiad tuaep.k ihTs iatpent ahs ghih T4 nad wlo THS chwhi ksmae ensse in a yrhhpidorety ttnepai, aprpesh uroy rtifs tthhugo si hatt hist pitetan sha v’areGs aissede. ,eoerwvH ni v’sGrae oyur oirdyth is gibne stietluadm to maek remo dryohit onmrohe form shcactr and sa such louwd aehv an acedinesr iorindiadeo takeup seceuab the hrodiyt is rnggbnii ni eht irqerued o(nw dlberoldaa)ie io.ndei iThs is why it is tno vreGas l(esra“ee fo itdhyro rhemoon ofrm a dyrthoi timlatused by .b)aio”esindt

oS if ist ont aveGsr’ hatw dluco ti e?b orF shti ’yuod ahev ot owkn ttha sahosHotim’ Tihisritdoy as(lo wnnok sa ircCohn hptyociLycm dsrThoiiity adn is ofnte redrfree to sa ushc on obdar sxmae to whrto uyo fo)f sah rhtee espash - stifr eyth are dhrhyyr,topie ehnt iohe,tydur then het ailscsc ytrhdopoiyh that uoy ulodw teecpx hwti owl T4 dna ihgh TH.S sThi aws eht yke ot siht itsoe.nuq hTe rsaeno fro tshi is htta ytrodiniath peeaiodxsr eitonsabdi in sas’moHhoit cseau eht rihydot to aleseer all fo sti roetds thoiyrd emhrnoo kanmgi teh ietnapt yhhetodriyrp ofr a osthr rdpieo fo .temi terAf shit viaemss erseela fo oidhyrt ,monrhoe eht esnabtidio amek meht bleuan ot kmea enw TH nda feorrehte hyet bceoem iodeyhtru for a ohtrs edprio nad tneh yoridhoyhpt wichh oyu dwluo e!ecxpt iceSn ethy anc’t aekm nwe ,TH hte rihtyod iwll otn tkea pu the odiedianiro nad ofreheter hteer lwli be lwo adrooiniedi u.eaktp Hee,nc “eselrae fo dstoer tdryioh rohmnoe mrfo a ytdroih dlgan rtiadlietnf by mothyc”y.spel aak hiytyLpocmc“ )hmssthaoo(i itiythrsdio.”

I tnikh “seaerle fo yoidhtr ehmroon rofm a mpuolahysmto odiyrth gan”ld is fegirrrne ot smeo ikdn of hdyoirt ccrean ni chihw ecas uoy wodul etexcp hetm to eb cnerdsbiig a elnodu no irdiiaoneod upae.tk

amSum​ry dvoei ehre adn asol a atgre eits in alnerg:e ierdnuehs/tqnoagem/.oyrhtericl//oea/:inpentrdpdcosi/d

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 +12
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

 +15  (nbme22#32)
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odoG ftac ot miocmt to my:omre uoy osle bcirba in teh sloto cnee(h ywh ehraraid eucass noiannon pag elobcatim ias)dsi,co nda yleeasilcp lose iumostasp ihtw xviateal ebaus s(a iodtmenen in het eountsiq )e.mst tl-em-a:o.idtbodii-ohpst-at.t/dwetb/newcheryr/npat/crraatoehsscui-lctowa-ewanetanlmdise

sbryant6  I'm going to go take a big bicarbonate poop now. +26
happysingh  i would suggest that you look into it a bit more. Why ? Had an nbme question (which confused the shit out of me) cuz, Bluemic Pt. who was abusing Laxatives (had the up & down arrows) and this is what it gave : Laxative Abuse — Metabolic Alkalosis :   ↓K+     ↑Cl-                   ↑pH    ↓HCO3- so one of the points of distinction IS the increase in Cl- with laxative abuse (vs. vomiting, which was a knee-jerk reaction when i hear bulimia) +2
lola915  I thought diarrhea causes Non anion gap metabolic acidosis @happysingh +1
texasdude4  easy way to remember : "Bicarb out the Butt" +




Subcomments ...

submitted by medstudied(0),
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Why si the ectcrro narews r-csqaeihu stet? I get ttha ’tis usde fro iaarcgcetlo blseavari tbu ’erew mnipgraoc pneraeeclv gerpena.estc sI ttah esiencrodd ceacla?rogti

liverdietrying  You’re looking at two categorical variables, Caucasian vs. AA and HTN versus normotensive. So you’re still using Chi2 to analyze. +6  


submitted by iviax94(7),
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rehTe evah eneb a opeulc of esnquisot aotub thsi potci no hte wener esam.x vIe’ neeb niwegnars yb uianqtge odilbi to ostseeornett elvsel adn onrltucna teonrscei to thlahe fo eltvarsucua riolseosrtha(ecs ro .)ton sI tsih crort?ec

liverdietrying  When you’re thinking of libido, don’t just equate it to testosterone -- make sure you’re always considering depression! Depression following stroke is common, especially with residual physical disability, so this would decrease his libido. Nocturnal erections equate to “does it actually work?” not just the vasculature but the neural input as well. For example, during prostatectomy damage to the pelvic plexus (nerves) can lead to impotence. There’s nothing to suggest that he has vascular or neurologic erectile dysfunction here, which is why his nocturnal erections are intact. +28  
_pusheen_  @liverdietrying Was it premature to assume he has trouble with erections because of neural damage from the stroke? I put low libido, low nocturnal erections. Is it because the stroke resulted in hemiparesis and not autonomic dysfunction or something like that? +5  
liverdietrying  @pusheen Correct, you won’t classically get impotence after a hemiplegic stroke. His inability to achieve an erection is much more likely to be 2/2 psychosocial effects than organic disease. If this vignette instead said that this had gotten a prostatectomy with resulting damage to the pelvic nerves that allow for erection, then it’d be a more safe choice to put no nocturnal erections. +4  
fast44  Is there a video or somewhere that explains these sexual dysfunctions? This seems to be a topic that keeps repeating on the new exams. +2  
forerofore  well, i though that because he had a stroke he would be likely to have atherosclerosis, which would keep libido high and reduce nocturnal erections, i kinda ignored the whole "he´s depressed" part of the vignette despite understanding the mechanism well. but from a clinical depression point of view, if his arteries are intact, and he is depressed, then libido would be low, and erections present at night. +4  
pg32  I can't remember exactly but I swear the question on NBME 21 the guy's wife had died as well...? Or they had gotten divorced? Either way, he had some psychological baggage as well, but his libido was still normal, and the explanation was that his testosterone would be fine regardless of his depressed mood. So I went with that logic here and missed this question. I don't understand how I am supposed to gauge someone's libido based on vague hints at their mood, especially when in one exam mood does not decrease libido and in the other it does. +1  
drzed  @pg32 bro spoilers +2  


submitted by iviax94(7),
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I was tweneeb haolypmaeik deu( ot aeaihr)dr dan hpprumec/imelyeyhcaariceair (sncie atsew si oyhicntop nda wdluo caesu ohcryipotems evomul n)n.ccittoora I itndd’ ahev a trega awy ot deiecd newebte ruCrpcpamreh/ayieyehi os I dgfeuri yhte nwdtae K.ohyp Is ehert a ebtter enaloitar rof why het pyreh esraswn era rntice?ocr

liverdietrying  I think you over-thought this one a little bit with the hypercalcemia/hyperuricemia. Good fact to commit to memory: you lose bicarb in the stool (hence why diarrhea causes nonanion gap metabolic acidosis), and especially lose potassium with laxative abuse (as mentioned in the question stem). https://www.uptodate.com/contents/acid-base-and-electrolyte-abnormalities-with-diarrhea +2  
w7er  Basically they are asking about electrolyte distrubance that cause collapse mainly due to hypokalemia from laxative abuse because diarreha cause hypokamlemia and also cause incrase in renin angiotensin sytem which will further cause hypokalemia resuling cardiocascular colapse :) +  
hyperfukus  i thought the hyperuricemia thing too but i wasn't smart enough to think they wanted hypokalemia like u :( +1  


submitted by iviax94(7),
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eerTh aveh enbe a eoulcp fo qsnseotiu auobt tish itpco on eth wener m.asxe ’eIv neeb gnsiwenar by gtiqeaun libido ot stetteneoosr evslel and nnualortc rnoieetcs to hhtlea of uevtacrauls tlae(oihscrroess ro tno.) Is hsit re?ortcc

liverdietrying  When you’re thinking of libido, don’t just equate it to testosterone -- make sure you’re always considering depression! Depression following stroke is common, especially with residual physical disability, so this would decrease his libido. Nocturnal erections equate to “does it actually work?” not just the vasculature but the neural input as well. For example, during prostatectomy damage to the pelvic plexus (nerves) can lead to impotence. There’s nothing to suggest that he has vascular or neurologic erectile dysfunction here, which is why his nocturnal erections are intact. +28  
_pusheen_  @liverdietrying Was it premature to assume he has trouble with erections because of neural damage from the stroke? I put low libido, low nocturnal erections. Is it because the stroke resulted in hemiparesis and not autonomic dysfunction or something like that? +5  
liverdietrying  @pusheen Correct, you won’t classically get impotence after a hemiplegic stroke. His inability to achieve an erection is much more likely to be 2/2 psychosocial effects than organic disease. If this vignette instead said that this had gotten a prostatectomy with resulting damage to the pelvic nerves that allow for erection, then it’d be a more safe choice to put no nocturnal erections. +4  
fast44  Is there a video or somewhere that explains these sexual dysfunctions? This seems to be a topic that keeps repeating on the new exams. +2  
forerofore  well, i though that because he had a stroke he would be likely to have atherosclerosis, which would keep libido high and reduce nocturnal erections, i kinda ignored the whole "he´s depressed" part of the vignette despite understanding the mechanism well. but from a clinical depression point of view, if his arteries are intact, and he is depressed, then libido would be low, and erections present at night. +4  
pg32  I can't remember exactly but I swear the question on NBME 21 the guy's wife had died as well...? Or they had gotten divorced? Either way, he had some psychological baggage as well, but his libido was still normal, and the explanation was that his testosterone would be fine regardless of his depressed mood. So I went with that logic here and missed this question. I don't understand how I am supposed to gauge someone's libido based on vague hints at their mood, especially when in one exam mood does not decrease libido and in the other it does. +1  
drzed  @pg32 bro spoilers +2  


submitted by iviax94(7),
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CT sohws assm on het etlf deis fo shi mboaned nad eryu’o ltdo tsi’ s.uiopinessutnct Assk which prat fo teh GI ttcar is ostm llieky to auces eth na.pi I lyiieemadtm koedlo fro oieacllce juncinto ... tno an saenrw .cihoec Why si hte serwna eumujjn .(vs dmuud)?one

liverdietrying  The picture is key here. You’re right that ileocecal is most common, but ileo-ileal and jejuno-jejunal are the next most common (I think I might just know this from having done clerkships already, not sure). Ileo-ileal isn’t an answer, so that rules that out. Look at where the arrows are pointing in the picture as well. Its on the L, ruling out appendix and cecum. And the slice is not at the level of the duodenum, ruling out that answer. So by process of elimination based on the picture you could get this one too. +4  
dr.xx  Duodeno-duodenal intussusception is a rare because of the retroperitoneal fixation of the duodenum. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529645/ +1  


submitted by airhead5(2),
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heT nwesar si ancroiacm fo eht barets. I teg ttha, btu ’mI vhgnai tuorlbe rgifigun uot hchwi nmacCiaro of taeBrs ti i.s m’I ucskt ewetbne SICD, nad vvensaiI ulcatD rcCamai.on I’m nagilne woartsd evsInavi tlDuac onrai,mCac sujt sebeuca s’it )(1 tosm ocnomm dna 2() teh mass itwh eurlrriag isgmanr in sersulct nsdosu eikl it ucdlo eb t‘sellaet ttrf’oanln,iii seen in isvvIena Dtluac ra.Cmiocna Btu I’m ont use.r naC oaynen leph?

liverdietrying  There is not enough information in the question stem to determine what kind of cancer it is. You would need a biopsy and histology information to determine that. However, this is definitely not DCIS since there *is* a mass. DCIS usually just shows up as small microcalcifications on XR (I’d google an image so you can see it). All the words they use here describe an invasive cancerous scary mass -- what kind of cancer can’t be known until they biopsy it! +2  


submitted by airhead5(2),
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soeD oeyann nkow eht eesdasi ythe ear gniatlk obat?u I asw ntgkinih pluus iwhch kmase nssee with the ,wasner ubt i nact’ idnf igahntny on rrneitao cabhrem fo eey adn odcirho xespul.

liverdietrying  It's lupus, all the symptoms listed are classic especially the serositis. Anterior chamber of the eye = uveitis. Choroid plexus = cerebritis. For a great overview, check out this (free) video: https://onlinemeded.org/spa/rheumatology/lupus/acquire +5  
in_a_pass_life  I think this was reactive arthritis, not lupus. Choroid plexus not just in the brain, also in eye (can’t see, can’t pee, can’t climb a tree). Mechanism of reactive arthritis is immune complex deposition, per UWorld, which was correct answer. +5  
trichotillomaniac  The inside of the eye is divided into two chambers: the anterior chamber and the posterior chamber. Both chambers contain fluid, and when there’s inflammation in the eye, a specialist can often see inflammatory cells in the fluid. https://www.hss.edu/conditions_eye-problems-lupus.asp +  
trichotillomaniac  I agree that this is Lupus after doing some more research! +1  
nwinkelmann  I find this article describing the SLE ocular manifestations, including uveitis and cerebritis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908056/ Also this talks about the lupus cerebritis (choroid plexus inflammation): https://en.wikipedia.org/wiki/Cerebritis +  
medulla  every time I read about Lupus there is something new!! +1  
aakb  woman of child bearing age + serositis + arthralgias/arthritis >=2 +  
aakb  kidney issues (main cause of death in sle) +