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NBME 20 Answers

nbme20/Block 2/Question#17 (59.9 difficulty score)
A 57-year old man has a hemoglobin ...
Chronic obstructive pulmonary diseaseπŸ”,πŸ“Ί

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submitted by hayayah(1100),
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hTsi si cievraet ohleyptamciy era,v cihhw is deu to gihh ldtaiteu ro ugln e.edisas OaS2 si ,wlo adn EOP si eied.scnar

onrehAt ayw to ahparpoc the sqeounti is nklogoi ta hte lbood s.rmea 'sIt teprty rmonla on( gkscemyatoyre,a on eadesricn buermn of atspte,ell no d,osr gnthion ul,eb )ec.t A boldo msare fomr a CPDO etaipnt lilw be no.ralm Jtus an cerniased nemubr fo sBRC eud to het csdinreae OPE dnageil ot edcresain Hg.b

mbourne  You shouldn't call it reactive polycythemia "vera", as polycythemia vera is a seperate disease with entirely different etiology. This is Reactive Polycythemia, or as another poster said, appropriate absolute polycythemia secondary to chronic hypoxia. +19  
j44n  i jumped on myelodysplastic thinking it was PV due to the jak w mutation but you technically get elevated everything in that mutation so it would be more than just RBC's +  
beetbox  I also thought it was PV. How can we tell reactive polycythemia from actual PV, if PV does not show other kinds of blood cell counts raised but just an isolate of RBC rise? +  

submitted by alexb(49),
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I cneosfud ctidlmesplosayy romeynds hwit pmrariy ebmysisfioorl ecseuba I gouthth 3-2 fo etsoh RsCB okledo leki paetrrod .sclle tsJu klie newh hety hosw na iagem for luosubl iidghpoemp nda e'etshr smoe dewir nscdoe rpi trohhug het uelmasebrldmard/ relay mgaink em tnhki 'sit nto PB evne uhtgho I dto'n onkw wath esel it wludo eb. flm

whoissaad  Made the same mistake +9  
targetusmle  i thought exactly the same!! 2 cells looked like tear drop cells :/ +2  
ilovemypuppies2295  I thought there were tear drop cells too. Seemed like it should be a metaplasia then. Oh well +  
lynn  I did the same, but looking at FA19 pg 423 it says "ineffective hematopoiesis --> defects in cell maturation of nonlymphoid lineage." You can get bilobed neutrophils, or if it progressed to AML you'd see auer rods. Nothing about tear drop cells. Then on pg 406 tear drop cells would be seen in myelofibrosis, and possibly thalassemias +  
waterloo  I thought the same, but I think that would be myelofibrosis, not myelodysplastic. Hb is really high here too. Pretty tricky for them to put that there, easy knee jerk. +1  
jawnmeechell  Interestingly enough, agnogenic myeloid metaplasia is the old name for myelofibrosis, with "agnogenic" being synonymous with "idiopathic." (or did everyone already know this) +  

submitted by strugglebus(172),
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Pt has ieymlayhpcto aevr rptfieolv(eoraiemly oe)rdidrs due to cornhic yihxoap nciudde by PDOC. oedilyM ltpaimesaa is atrxe lymedrlua sohometpseiai eud to fimbisryols.eo ayrereiHdt cmeoaoshhitroms wodul evha eebn prnoev yb a rpaussni eubl a.stin Hsinepmrysple lwdou ehva sudcae deesedrac BCR,s adn oyssyliaelmdcp emrdynso wludo ehva nhwso reuA odrs or absslt.

neonem  Right, I think this would be just called "appropriate absolute polycythemia", whereas polycythemia vera is due to a malignant JAK2 mutation and would be termed a type of chronic myeloproliferative disorder. +14  
utap2001  Myelodysplastic syndromes (MDS) is also called Preleukemia, myelodysplasia. in MDS, your bone marrow doesn't make enough of these healthy blood cells. Instead, it makes abnormal cells that aren't fully developed (immature). As the condition develops, your bone marrow gets gradually taken over by the immature blood cells, which don't work properly. The condition can develop slowly (indolent) or quickly (aggressive), and in some people it can develop into a type of leukaemia called acute myeloid leukaemia (AML). +