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NBME 22 Answers

nbme22/Block 1/Question#26 (43.5 difficulty score)
A 42-year-old man comes to the physician ...
Hydrochlorothiazide🔍,📺
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 +9 
submitted by meningitis(574),
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oiloydrdcehohhaoizrt si DCO rfo crpNoenhegi eDtaibse susdpiiin sebuace it dycarpxliaoal cuessa an icensaer ni PB yb scrnaeingi idousm oprbasonit and thus rweta pnai,trobso athoPma sexipnal thsi yi.ecnl

nDssspeorime is iorecncrt secbaeu uopn ngsatif lf(udi ctrtsnor)eii AHD is aencedris amingne HAD si egibn arledese lelCynatr but si nto wrnkiog in the kineyds ta eht 2V escrroetp fo het lleitpahie lraen eslcl ta cgeCnllito ct.du

nO that tn,eo ioidmAelr is esdu rfo iumLiht dicuend epnngihcero DI.

hello  Where in Pathoma? I couldn't find it. +1  
almondbreeze  also sketchy says that thiazide s decrease the amount of lithium cleared--> lithium toxicity +1  
paperbackwriter  Agh confused as well because FA2019 (pg 562) says that thiazides are implicated in lithium toxicity D: +  
paperbackwriter  OOPS, please ignore last comment. I just realized that this Q stem never mentioned lithium. And on top of that @meningitis mentioned that amiloride is used if lithium induced. Apologies. +  
jaramaiha  Question is nephrogenic DI. ADH is increased but kidney's aren't reacting, mutated receptors. In which the Tx is HCTZ +  



 +4 
submitted by gh889(134),
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gnccairdo ot tupeatod hzidasite sucae a ldim epvlmychoio state tush royu PCT lilw ees omer aN dan 2OH &-tg-; yb iipercpnl that teh PCT ylsaaw oarsbsbre %60 fo thaw ti sese, ti llwi ebrrasob omer tarew dna Na.

almondbreeze  in sketchy as well +  



 +0 
submitted by asapdoc(69),
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ttePina sha erngcnpohie isDbetea .nupIdiiss Oen of het nrtmeatets si lichidyda.orrzotehH

meningitis  hydrocholorothiazide is DOC for Nephrogenic Diabetes insipidus because it paradoxically causes an increase in BP by increasing sodium absorption and thus water absorption, Pathoma explains this nicely. Also you shouldn't have chosen Desmopressin because upon fasting (fluid restriction) ADH is increased meaning ADH is being released Centrally but is not working in the kidneys at the V2 receptors of the epithelial renal cells at Collecting duct. On that note, Amiloride is used for Lithium induced nephrogenic DI. +1  



 -1 
submitted by waterloo(89),

Just to add thought process. Pt has excessive thirst, and urinating frequently but his Serum osmolality is increased...which means he has to omuch solute in his blood and his ADH is not working.

ADH not working can be due to Central DI or Nephrogenic DI. Central DI is when pt has lack of ADH but in this vignette they say the ADH is increased --> must be nephrogenic.

I don't think you need to know that HCTZ paradoxically works for nephrogenic. I think you can save time and just memorize FA's tx choices for Nephrogenic DI - HCTZ, amiloride, and indomethacin. You could argue it's good to know mechanisms, but I think knowing the drug names and their MOA, you'd be able to figure it out if they went for a 4th order reasoning (there's already enough thinking to do in this question)