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NBME 20 Answers

nbme20/Block 1/Question#17 (84.2 difficulty score)
A 50-year-old woman comes to the physician ...
Drug effect🔍
tags:

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 +26 
submitted by strugglebus(163),
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eeorhwN eahv I bnee leab to fnid hyw the hell this si a htngi.

yotsubato  Its not in FA, Sketchy, or Pathoma, or U world. I knew it wasnt cancer because its bilateral. And Diabetes made no sense to me. So I just threw down Drug effect and walked away. +6  
breis  same^^^ +  
feliperamirez  The only possible explanation I think is that she was under a K sparing diuretic, such as spironolactone (which would lead to gynecomastia). +  
chandlerbas  you had me at its not in sketchy ;) +1  
j44n  i thought HTN induced empty sella would cause this because they got type II diabeetus. So if you need a pro zebra hunter holler at me. +  

https://www.mayoclinicproceedings.org/article/S0025-6196(11)61587-5/pdf#:~:text=Other%20classes%20of%20medications%20that,dis%2D%20turbance%2C%20and%20impotence.

if you want to save your time and not read an 8 page research article like I did heres the summary

Other classes of medications that cause hyperprolactinemia include antidepressants, antihypertensive agents, and drugs that in- crease bowel motility. Hyperprolactinemia caused by medications is commonly symptomatic, causing galactorrhea, menstrual dis- turbance, and impotence.

+/- j44n(42),


 +19 
submitted by hello(302),
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Galnjo adh a elcreut thta menednito hatt "If a petitan has legaahrtc,roa wvreie veeyr durg e'hyert iakngt niesc yman ugrds sceau troag.ahaclr"e

ehT ynol tinhg of elsbisop cevrneale in ihst mQ-ets is ttah ehs aetks a dteionmai,c eoerrhfte het rsanwe fo "urgd c"eetff si the msot ilekly eaonrs for her taoerhcraal.g

hungrybox  I still think this question is pretty BS. But having studied some more, I think it's less BS than I originally thought. Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question. +5  
hungrybox  To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs." +2  
hungrybox  The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc." It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect. +2  
drdoom  hungrybox’s full comment (below) here: https://nbmeanswers.com/exam/nbme20/410#3907 +1  



 +12 
submitted by strugglebus(163),
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As an 1,e 1800i:t0d pepeol dtropree to heva sedi esfefct hnew agntik ozHraoy erdhonghiAdml.coit hetm, 52 peeplo 20)0.%( ahve Bresta adersigch

neonem  I think the best way to answer this question was by process of elimination. +1  
sympathetikey  That's some bullshit lol +8  
karljeon  Haha I eliminated the answer by process of elimination. +19  
medschul  I eliminated thiazides by process of elimination :( +1  
medstudent65  Shit I eliminated thiazides because of elimination went with HTN thinking intercranial bleed effecting the pituitary +2  



 +2 
submitted by fkstpashls(16),

Process of elimination is the only way to get this answer without Savant levels of autism, as some bowtie wearing doucher who wrote the question probably has.

Cancer is unilateral almost all the time, DM doesn't make sense for any reason, HTN itself wouldn't cause milky boobs, and mast cells degranulating doesn't make milky boobs either. So, and because many drugs can have milky boobs, you're left with drug effects by process of elimination.

djinn  I dont think the autor was a savant. Also I think is right proccess to think "cancer" can be bilateral and malignant but the "drug" that causes this isnt HCT. This question is bad written. +1  
hungrybox  According to Pathoma, galactorrhea is NOT associated with cancer ever (see 16.1 - breast pathology). +  
djeffs1  according to strugglebus's numbers its more likely to be b/l cancer than thiazides... +  



 +2 
submitted by niboonsh(338),
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" hetOr lscesas fo isimentocad that escau trpcihenilpoaearmy cueilnd raesnsta,snitpde aveetntyeinisrhp a,etngs dan grusd htta rincaese owebl moi.ytlti eaotlnmyaipierprHc sudcea by ticeaodismn is lmmonyco pic,mtamotys agsiucn garthoarl,cea runmtlase neubadr,scit dna ete.nmcoip tI si Iantopmrt to nurese ttha plrorahpeeyicatnmi ni na ivdindIual tpeniat si ued to ntidieocam and nto ot a lacsttrruu seinol ni het rtpu/ptaltmcahiyihyoai aear; sthi acn eb ehcicadolpsm yb 1)( ptogispn teh oiaitdcmen itmraylproe to ntemdeeri hhwreet ciparlton levsle rnrteu ot mrl,oan (2) iticnghsw to a teiaoidmnc htat edso tno aseuc rahepcmlipyatrneoi "

9i/vn8n.pm0/.l5/wbw/t2hb4g.n6uedomsict.w:p1h

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 +2 
submitted by hungrybox(977),

Pathoma gives the three major causes of galactorrhea as nipple stimulation, prolactinoma of anterior pituitary, and drugs (see 16.1 - Breast Pathology). Only drug effect is an answer choice for this question.

To put another way - before you try to go through every answer choice, asking yourself "would this cause galactorrhea?" Instead, ask yourself, "What are the causes of galactorrhea?" According to Dr. Sattar, they are "nipple stimulation, prolactinoma of anterior pituitary, and drugs."

The question doesn't say anything that would point you toward nipple stimulation, like "it only seems to appear when she puts on a shirt/plays sports/runs/etc."† So you can rule out nipple stimulation.

It also makes no mention of bitemporal blindness (which would point you to an anterior pituitary tumor), so you can rule out prolactinoma. The only option left is drug effect.


I've never seen anything like this on a question but I assume the NBME would word it in some convoluted way like that.


I initially wrote this as a subcomment, but I feel like it deserves its own comment. I was never really satisfied with any of the explanations for this problem, and I finally arrived at one that makes the most sense to me.

hungrybox  Oh, and besides, nipple stimulation and prolactinoma aren't even answers lol +  
drdoom  [system mailer] your account has been upgraded: FORMAT NINJA +1  

One more thing: Pathoma specifically says cancer is NOT a cause of galactorrhea.

So the people who are saying you can rule out cancer because it's bilateral are completely wrong. You rule out cancer because it doesn't cause galactorrhea.

Besides, breast cancer can be bilateral. Bilateral breast cancer is almost always invasive lobular carcinoma.

This is analogous to serous cystadenocarcinoma. Bilateral ovarian cancer is almost always serous cystadenocarcinoma.

Idk how this "breast cancer can't be bilateral" myth started propagating.

+4/- hungrybox(977),


 +1 
submitted by dave_(1),

Thiazides reduce GFR -> Reduced clearance of prolactin -> hyperpolactinemia -> discharge.

Not sure how correct that is, but aside from cancer being unilateral, I would associate high prolactin with loss of dopamine inhibition/reduced clearance of prolactin itself.




 +1 
submitted by sam1(16),
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siahizeTd cna esacu ueatc nlaireiittts ,esnrpitih a rmfo of arlne arul.ife Wutoith eth anelr tecenirxo fo ,tcrnlaipo ti anc idubl up in het seumr dna lestru ni c.ghaerrtaoal

coccidioinmytitties  Sexual dysfunction [desire based = libido] can be due to drug side effects [antihypertensives], per first aid. Edition: 2018 Page: 551 Section: Psych Per, 1stAid's endocrine section: "excessive amounts of prolactin associated with ↓libido [324]. This goes together with our sexual dysfunction with "antihypertensives." Only logical synthesis I can think of: thiazide = ↑prolactin = ↓libido + galactorrhea. It would also make sense since we are dealing with an expected to be post-menopausal female [milk production would have to be due to exogenous source]. Dug into my lecture notes and found the following: beta-blockers and thiazides cause sexual dysfunction. I also like sam1's explanation. We're reaching here, but its the best I can do. +  
g8427  Mayo clinic shows clear or bloody nipple discharge as side affect of Thiazides. But doesnt state milky discharge. +  



 +1 
submitted by namira(30),
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sesboPil :axpltoannei

If het tp si ntakig a iaithedz c(whhi is K igete,)dlpn ti migth eahv saol ebne ivnge ihtw a K asigrnp urgd cush as s.nproticeoianl

lnocStaoiperin ash iecroodniglcon fcesfte husc sa aiegtscaymno nda lr.actagearho

sugaplum  I think you could only make this assumption if they said "patient is on standard htn tx" but since they gave the name hctz, would not be fair to assume they are also taking spirinolactone. I went with process of elimination on this one. Even checked access medicine's drug adverse effect profile...galactorrhea not listed for hctz +2  



 +0 
submitted by j44n(42),

Possible causes of galactorrhea include: Medications, such as certain sedatives, antidepressants, antipsychotics and high blood pressure drugs. Opioid use. Herbal supplements, such as fennel, anise or fenugreek seed

^ from the mayo clinic.... emphasis on the HTN drugs




 -4 
submitted by minhphuongpnt07(6),
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dtighia;Tz&e= camtrhyp&;aei=eclg oxniOxyt Gq( pdelcou oe-ti;&gntrp cirn 2+&gC=);at lipenp cradseghi

arkanaftus  Oxytocin will not work on breast resulting on milky discharge if the glands were not "prepared" by prolactin. It's like trying to squeeze empty balloon - nothing goes out. +