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NBME 20 Answers

nbme20/Block 4/Question#13 (63.6 difficulty score)
A 62-year-old woman comes to the physician ...
Bronchogenic carcinoma🔍,📺
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 +7 
submitted by xxabi(267),
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Bcceoinnogrh rnmacaoic = gnlu acercn

tTha nbige d,sai gunl admacennoracoi pllficyescai si edostasaci ithw hrhppyrcoeit o,hotaehpyorratst hicwh is a ciatapsponlera esodrynm ehaeiracztrdc yb tiagldi inlbcg,bu r,garthalia ntjio ,sfuiesofn and iitosrposse of uuralbt nosbe

luke.10  why not systemic scleroderma since i did this question wrong and i chose systemic sclerosis scleroderma , can someone explain that ? +2  
kernicterusthefrog  My best guess answer to that @luke.10 is that: a) there's no mention of any skin involvement (which there would be in order to be scleroderma) b) Scleroderma shows pitting in the nails, not clubbing c) There would be collagen deposition with fibrosis, not hypertrophy of the bone at joints Saying that, I also got this wrong! (but put RA...) so I'm not claiming to "get this" Hope my thought process helps, though! +6  
yotsubato  This is in FA 2019 page 229 +10  
larascon  I agree with @kernicterusthefrog on this one, Bronchogenic carcinoma = lung cancer. Squamous cell carcinoma gives you hypercalcemia (new bone formation; maybe?), commonly found in SMOKERS ... +3  
waterloo  the clubbing is the symptom that takes out alot of the answer choices. It's super tricky. +  
jawnmeechell  Plus the patient has an 84 pack-year smoking history, super high risk for lung cancer +  
veryhungrycaterpillar  FA 2019 pg 229 is all paraneoplastic syndromes. There is no mention of bronchogenic carcinoma in any of them. There is adenocarcinoma, but that is most likely in non smokers, not in someone with 84 pack year of smoking history. Why does he have 5 upvotes for referencing first aid here, what am I missing? +3  
jakeisawake  @veryhungrycaterpillar sounds like bronchogenic carcinoma is a general term for lung cancer. You are right that if a non-smoker gets lung cancer it is most likely adenocarcinoma as non-smokers rarely get small cell. However, smokers can get adenocarcinomas as well. The oncologist that I shadow sees this frequently. Adenocarcinoma of the lung causes hypertrophic osteoarthropathy per 229 in FA2019 +2  
mangotango  @verhungrycaterpillar @jakeisawake Adenocarcinoma is the most common tumor in nonsmokers and in female smokers (like this patient), so adenocarcinoma would still be the most likely cancer for this pt over the others. Pathoma Pg. 96. +3  
fatboyslim  Apparently bronchogenic carcinoma is basically an umbrella term for lung cancer. Source: https://radiopaedia.org/articles/lung-cancer-3 +  
lifeisruff  bronchogenic is another term for adenocarcinoma in situ according to pathoma +  
topgunber  With the exception of mesothelioma- 95% are bronchogenic +1  
meja2  @lifeisruff No, bronchogenic carcinoma is a blanket term for all lung cancers. However, the adenocarcinoma in situ subtype is called Brochoalveolar ca. Ref: FA 2018, pg 665. +1  



 +3 
submitted by niboonsh(369),
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ofndu stih lnein:o l//cs/m1hr/0e5yp2:k0taiu8acadmueo/pi4ao4mec0t9cpr0/./hrt/.5

cepHorrhiypt alpuynrmo ttoastarrooyphhe (P)AHO si a remsyndo deczahearirct by het tardi fo tssiietio,pr gaiidtl bglbciun and iufpaln aapttohyhrr fo eht lagre jns,iot ayscilelpe oviivglnn eth welor bi.sml ubnilCbg is cerdheatiacrz by lbbuous nrtlnemaege fo teamlnir smtseneg of het ensrigf dan oest deu ot rialoinrepotf fo ubngasuul cceovnitne .etsuis

p.ai.r.myr is a rrea aythdeirer ico.nndoit

A rtyijoma of aecss ;0(9)%gt& fo yadrnscoe HAOP aer asdaciseot tiwh pyrumolan ncgaimanlise ][6 or rniccho auepuivrstp ypanrmuol esse.asdi

yPlamurno gcl,inamneais ngildnuic rraympi ][,7 iaecttasmt ugln rcenca nad rritioahtcanc ohayp,lmm utocanc rof 0%8 fo escas fo ranscodey H.OAP icmarnaodeoAcn fo teh gunl si het smto etnuefqr adn llasm llec raocnmcia is teh ltsea urtfenqe otashiogochplti peyt of nlgu carnec saaticesod hiwt AOPH ][.7

rehto dstsaeioca aatorexthircc nnisimgcalea iucedln nhnolasepgayar mcracn,oai earln ellc mcaonr,iac sapeolhgoae c,ecnra atsrgci orumut []8, rcetcianpa ,cenrca bsetar edlhpyosl uuotrm ]9,[ ,amolnema thiydor cc,nare cotoamreasso and alntesniit oaypmlmh.

aosruiV uilehmgotcroa isodtionc,n ciidngnlu RA []10, SA [11,] istiolrtaypre nd,osao SEL 1[2,] kaTyauas deiseas [3]1, iosdisrc,osa PSA and inerdtrneaMea ervef are wnonk ot be acsotadies htiw hist tndcnioio sa ell.w

ayPolrmun nnosiictod shcu as ciysct ,risisfob ,euucrltsobsi hciiaiodpt pmunroayl obssfrii 1]4[ and lgun ritnlstatapnnao eavh saol nebe saidaoctse tihw AO.PH




 +2 
submitted by queenofhearts(14),

This patient has hypertrophic osteoarthropathy which is associated with bronchogenic carcinoma. It presents with painful swelling of wrists, fingers, ankles, knees, or elbows. In addition, the ends of long bones show periosteal new bone formation , which can produce digital clubbing and often arthritis of adjacent joints.

Resource: Kaplan Bone Pathology Page 237




 +0 
submitted by tulasi(0),
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The etnnesaroipt of eciorihncngB aomncraci hC-i guso adn hsTth ymespie ourtt miseasttsa ot ngburonaLeB,,in dna sarndl .ae So own het ieqotnus si mnetgoinni eth esam tiopsn heT cuohg dan mpsuut and olas ewn oenb omriotanf on cteedffa boesn no yXar dna alos cbiglbnu sprrteseen hte lg.nu

-nrfeceeeR 010 ntosccpe fo omatayn diels 49

tulasi  Also its cell type is squamous cell carcinoma like not adenocarcinoma like. +  
tulasi  Also its cell type is squamous cell carcinoma like not adenocarcinoma like. +  
tulasi  Also its cell type is squamous cell carcinoma like not adenocarcinoma like. +  



 +0 
submitted by assley(1),

Hypertrophic osteoarthropathy is a medical condition combining clubbing and periostitis of the small hand joints, especially the distal interphalangeal joints and the metacarpophalangeal joints. Distal expansion of the long bones as well as painful, swollen joints and synovial villous proliferation are often seen. The condition may occur alone (primary), or it may be secondary to diseases like lung cancer. Among patients with lung cancer, it is most associated with adenocarcinoma and least associated with small cell lung cancer. These patients often get clubbing and increased bone deposition on long bones. Their presenting symptoms are sometimes only clubbing and painful ankles. Hypertrophic osteoarthropathy is one of many distant effect disorders due to cancer, with lung cancer being the most common cause but also occurring with ovarian or adrenal malignancies. b) bronchogenic Ca. and the only answer thats relates to lung cancer and all other answers do not. I chose RA, but if you don't know...now you know.




 -2 
submitted by step1soon(46),
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eTh tordreep iciednnce of naCalp ysmnredo si 1 in vyere 010000, oplp.ee ihTs sha eebn a gdneilnic ubremn ued to worel rseexpuo to alco, sab,setos dan iical.s nvacreePel of aaCpnl meoyrsdn is heghir ni sttepain whit iaislc erueosxp adrpmoec to eht otehr s.eucas hTe frist idgemooicpeli tyusd drantnekue by eht ioincemnuossPo heasRcre nUti svboerde an rneasedci earelpcven of AR gnsotma emn ithw griovsepers aesmsvi fisriobs F.()MP liMal et .la ufnod no ederaicns rnacelvpee of ureaidthmo shairtitr ni mrnies ehnw peomdcar to a mytomincu herew FPM nda ahoidutrme srrhtatii rwee tnperaelv nad fotereher ccunldedo ahtt eth oltygieo of RA swa ont satadcsoie htwi exsrupeo to stud ro ulng csgahen fo tcclodepami n.ooipsocumiesn ehTer saw a hgih nerecplvea rtae of PMF dna eilrboustusc tongasm erinms nad mieesrx-n htiw hiaemtdruo a.siht]][rr4i5t[

pyhPAo t:hgioaysnlo auemumtnio doinictno si a mhpeonnone wehre 'oens oydb hsa yotfmraanmli sellc ihhcw akatct tis nwo tssieu nd,a in hte scae fo ,AR eth smonyvui. tI si vebileed htta in teehs tsipnat,e heetr is na itoaatlnre hwihc sucaes teh eecasirnd meumin eerssnop to einrgof lesrmiaat ni hte .lsnug eThre si mienum pierhayittcyv htat si sepkadr by iscial in hhwic otcoenysm and aagmopersch lseeera ncytsokei such as inu1kn-lieetr dna iunulapgyy-anmh-mcgorostiaectgl-aontcloer rtoafc dna umtro rsnoiesc fracot hap.al ehT sraph dgese fo teh siailc olsa uscae yliss fo yllsomsoa sorpetsea in gempo.acshar eyopymthcLs rae tacvtiade by teh steynkcoi eledarse by sagprcomah.e iTsh lal aldse to an naoutueimm poohemnnen turhogh pxerueso to islcai chihw is idereggtr ni eeliaclyntg rpsdoipeeds iaivsndldiu owh vahe .AR

ldnwtou' teh dgnlynruie edeasis be AR cwihh is nteh sucgain ihrcbecnongo oacanc?irm m'I !efsocdnu!

kpjk  i dont think its RA, because they said xray shows new bone formation, where as RA would have erosion +1