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NBME 21 Answers

nbme21/Block 3/Question#32 (22.0 difficulty score)
A 72-year-old man comes to the physician ...

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submitted by lilmonkey(19),

Chemo-tox man picture from the FA (last page of the hem and onco section) works well for me in these types of questions.

lovebug  Bleomycin Induces free radical formation -> breaks in DNA strands.(Anti-tumor effect) FA19, pg431. and other tissues have Bleomycin Hydrolase. but Lung doesn't. So lead to Pulmonary fibrosis. +  

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yotsubato  Bleomycin is the big boy of cancer treatment. I've never heard of chlorambucil and its not in FA. +1  
vulcania  I had never heard of chlorambucil either and after researching it found out that it's also an alkylating agent, specifically a nitrogen mustard - same as busulfan, so you weren't wrong! Based on what FA says re: bleomycin & busulfan (extrapolating this to chlorambucil), they both cause pulmonary fibrosis & skin hyperpigmentation, however, in the Lange Pharmacology flashcards it says that the hyperpigmentation with busulfan is from adrenal insufficiency so I guess you would expect to see symptoms of that as well if the same applies to chlorambucil? +1  
vulcania  jk ignore my previous comment. just checked uptodate and it doesn't list hyperpigmentation as a side effect of chlorambucil. +  

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submitted by dr.xx(125),
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