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Comments ...

 -1  (nbme22#12)
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hyW otn G2PI yb yaw of ?AAS cplaisyelE evnig ohetr asewnr choicse of orsinetp C + S: ntdoe's nirrawfa saol sruspeps eh?tse

imnotarobotbut  Protein C and S are ANTI-thrombotic, so although Warfarin does decrease them, they wouldn't decrease the patient's risk for thrombosis +1
epr94  the question ask "suppression" of which one will decrease risk of thrombosis if you suppress C and S which and anti-thrombotic you get thrombotic +2

 +0  (nbme22#46)
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hSmwooe I swa ebla ot eccnnovi slymfe hatt crieandes tsersnooette tg-;-& eeesadcrd nrestgeo g-&t-; aeeeddrcs enivaegt eackbdef on HH/SFL cesiorent ;gt--& daiersnec HFS. eoDs anneoy raec to plxiean yhw htis giocl si w?gron kanhTs ):

btl_nyc  The increased testosterone is metabolized by granulosa cells to estrogen and by adipose tissue into estrone. Both feed back on the hypothalamus to inhibit FSH & LH secretion, but FSH is much more sensitive to feedback inhibition than LH, causing an increased LH/FSH ratio. +1
impostersyndromel1000  @sup, i did the same thing. Had no idea testosterone and androgens can increase epo +

Subcomments ...

submitted by yotsubato(1041),
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hyW anct sthi be tieavla?sx hoBt udowl cesau lbcotaiem lossilaka whit .ahmikeoal..yp ?

sup  Laxatives would cause an anion gap metabolic acidosis due to loss of bicarbonate in the stool. You would see hypokalemia though as seen in this question. +1  
miriamp3  it took me a lot of time choosing between laxatives and diuretics and at the end I choose diuretics. but I didn't realize that the only thing I had to do was check if were a anion gap or not. +  
snripper  Why would laxatives cause anion gap MA? Isn't it similar to diarrhea? +  
castlblack  The above comments are incorrect. Diarrhea is a cause of normal-anion-gap metabolic acidosis (D in HARDASS from FA). Laxatives are wrong because they would lower HCO3- but in this scenario it is high. The low K+ and Cl- fits either case though. +4  

submitted by oznefu(22),
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Im’ ngaivh teobulr grenituddnnas yhw this si a teetrb iechoc hnta agPet sseea,di lyaceiepls twhi the iesdercan ?PAL

zelderonmorningstar  Paget’s would also show some sclerosis. +5  
seagull  ALK is increased in bone breakdown too. Prostate loves spreading to the lumbar Spine. It's like crack-cocaine for cancer. +28  
aesalmon  I think the "Worse at night" lends itself more towards mets, and the pt demographics lean towards prostate cancer, which loves to go to the lumbar spine via the Batson plexus. I picked Paget but i think they would have given something more telling if they wanted pagets, histology or another clue +1  
fcambridge  @seagull and aesalmon, I think you're a bit off here. Prostate mets would be osteoblastic, not osteolytic as is described in the vignette. +17  
sup  Yeah I chose Paget's too bcz I figured if it wasn't prostate cancer (which as @fcambridge said would present w/ osteoblastic lesions) they would give us another presenting sx of the metastatic cancer (lung, renal, skin) that might point us in that direction. I got distracted by the increased ALP too and fell for Paget :( +1  
kernicterusthefrog  @fcambridge, not exactly. Yes, prostate mets tends to be osteoblastic, but about 30% are found to be lytic, per this study: Additionally, the night bone pains point to mets, and Paget's is much more commonly found in the cranial bones and appendicular skeleton, than axial. This could also be RCC mets! +  
sweetmed  I mainly ruled out pagets because they said the physical examination was normal. He would def have other symptoms. +4  
cathartic_medstu  From what I remember from Pathoma: Metastasis to bone is usually osteolytic with exception to prostate, which is osteoblastic. Therefore, stem says NUMEROUS lytic lesions and sounds more like metastasis. +5  
medguru2295  If this is Metastatic cancer, it is likely MM. MM spreads to the spinal cord and causes Lytic lesions. It is NOT prostate as stated above. While Adenocarcinoma does spread to the Prostate, it produces only BLASTIC lesions. +  

submitted by hello(316),
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ntePait ni oiclmpoeyvh schko - hte cuesl aer lwo PB and OOLC pliycvoHoem hokcs si sdcaue yb fuild sols.

The naittep sha redcesdae reaolpd /cb of dilfu s,los ei.. etehr si rdsdeeeac dlobo lemvuo rrtueignn ot terah &-;t-g hust sedercead pod.eral

endochondral   why not dec SVR? +  
sup  @endochondral w/ hypovolemic shock you would see increased systemic arterial resistance as arteries will constrict to try and bring BP back up. +1  
eacv  @endochondral dec SVR it typicaly of septic shock. +  

submitted by medschul(89),
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I acn gte hebnid lnagsmy,epleo btu tawh is the osir?dred

sup  Felty syndrome, an extraarticular manifestation of RA. Symptoms include a triad of RA, splenomegaly and neutropenia. It's in FA, you just have to squint (look at the fine print under the RA vs OA table in the MSK section). +21