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NBME 22 Answers

nbme22/Block 2/Question#7 (69.4 difficulty score)
A 66-year-old man comes to the physician ...
Libido: decreased;
Nocturnal erections: normal
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tags: erections penis libido 

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 +5 
submitted by paperbackwriter(114),

SPOILERS FOR NBME 21 -- DON'T READ AHEAD IF YOU HAVEN'T TAKEN 21

After getting it wrong (because of the NBME 21 Q), I understood it like this:

– Libido is a long term state, meaning your libido could be fine, but anxiety in that MOMENT might cause psychogenic ED

– This guy has some classic SIG E CAPS criteria going on: fatigue (energy loss), sleep disturbances, concentration problems

– It says he hasn't been able to maintain any erection (vs NBME 21 guy that was able to masturbate (his long term sex drive was OK) but had performance anxiety in the moment)

Therefore, lack of sex drive fueled by depression --> low libido, but physiologically nothing wrong with him --> nighttime erections

trump2020  Bless you for including the spoiler warning +2  
kernicteruscandycorn  @paperbackwriter: sick name and reference +  



 +3 
submitted by iviax94(7),
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Teehr eavh bene a plueoc fo neotsuisq ubtoa siht cpoit on hte nrewe xms.ae evI’ nebe anirsewng by uqniegta iolbid to otetesoretns llseve nda laourtncn istroenec to elthah of atuucsvarel lre(sthoscsoeria ro )ton. Is shit erocrct?

liverdietrying  When you’re thinking of libido, don’t just equate it to testosterone -- make sure you’re always considering depression! Depression following stroke is common, especially with residual physical disability, so this would decrease his libido. Nocturnal erections equate to “does it actually work?” not just the vasculature but the neural input as well. For example, during prostatectomy damage to the pelvic plexus (nerves) can lead to impotence. There’s nothing to suggest that he has vascular or neurologic erectile dysfunction here, which is why his nocturnal erections are intact. +28  
_pusheen_  @liverdietrying Was it premature to assume he has trouble with erections because of neural damage from the stroke? I put low libido, low nocturnal erections. Is it because the stroke resulted in hemiparesis and not autonomic dysfunction or something like that? +5  
liverdietrying  @pusheen Correct, you won’t classically get impotence after a hemiplegic stroke. His inability to achieve an erection is much more likely to be 2/2 psychosocial effects than organic disease. If this vignette instead said that this had gotten a prostatectomy with resulting damage to the pelvic nerves that allow for erection, then it’d be a more safe choice to put no nocturnal erections. +4  
fast44  Is there a video or somewhere that explains these sexual dysfunctions? This seems to be a topic that keeps repeating on the new exams. +2  
forerofore  well, i though that because he had a stroke he would be likely to have atherosclerosis, which would keep libido high and reduce nocturnal erections, i kinda ignored the whole "he´s depressed" part of the vignette despite understanding the mechanism well. but from a clinical depression point of view, if his arteries are intact, and he is depressed, then libido would be low, and erections present at night. +4  
pg32  I can't remember exactly but I swear the question on NBME 21 the guy's wife had died as well...? Or they had gotten divorced? Either way, he had some psychological baggage as well, but his libido was still normal, and the explanation was that his testosterone would be fine regardless of his depressed mood. So I went with that logic here and missed this question. I don't understand how I am supposed to gauge someone's libido based on vague hints at their mood, especially when in one exam mood does not decrease libido and in the other it does. +1  
drzed  @pg32 bro spoilers +2  



 +2 
submitted by elf16(2),
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Hwo si iths rdefieftn rmfo eth utoeiqns no NMBE 12 in cihwh a r-6yea8 old mna salo had pyccsigoneh ED? uBt the nwasre saw aonlmr lioibd nad olurntcan one.eitscr

toxoplasmabartonella  In that case, his testosterone was normal and he had no signs of depression. The stem did say his wife passed away few months ago, so i personally chose low libido, but whatever. +  



 +1 
submitted by adong(97),
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ettryP hcum if they acn umabtesrat ro egt it up oealn in ayn awy tihre aocnrtnlu steumccene dlshuo eb naorml nngimae atht hetri anioevtnnir nad rxflee tspwayah rea lal catnt.i diboLi kaa esx iderv fomr hwat v’eI ense so arf is ertdela yb rs.isoeendp oS like in the uinoseqt on ENMB 21 eht smte tsteda hatt cgiensner rfo srnspoedei swa ginevaet wihhc is hyw idlboi lwuod aosl be mnraol in htis .asec fI ese’rth veer a Q whit a dsedpeers ugy and nlamro lba sluave nda iplhysca aemx, msto lylkie agnon be edrsedcae bodlii htwi monrla gniht ceesn toir- eytosrcu fo naei/aslujrinodufux/yf




 +1 
submitted by nwinkelmann(297),
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So, I tuthhgo shti oestuqin aws pesur gueva nda tno .ge.t.ra htta inbeg ,asdi hviagn ttngeo it grwon adn ont leryla ghvian a ogdo nxeiptaolan orf het es,nwar I did a ttllei eahsrrce and fnoud tihs ci:treal wS.it1.1Taf.1/:l.03/w1doga.o5s0.7t/rrop.np0/61a1hdwRjhs/u/4

hTsi saw het ainm ccuniloo:ns heT" sslertu fo het repntse ,stdyu edmai at nsgiessas hte ctsfefe fo rotkes on auelsx niofting,ncu lvaere a tiniginsfca liedenc ni bdili,o oicalt eyf,eqcnru asxelu ,asualro and fsanitasoict wiht euasxl elfi in tohb oketsr piseatnt adn tihre oesspus. eTh tpesern tssurle aosl etdnetasrmo that esdsrroid fo usexal cftnisuon rae somt inlsnactgyiif itescodaas htiw uoisvar oshocsaiyplc cafrs,ot cuhs sa neti’tasp rnalgee ttuatdei dwtaor xasytiuel, erfa fo noe,citpme dna ibitlya ot dsissuc t,ulyeixsa as lwle sa ihwt eht edereg of krtpooests ltcniafnou .sidibtlayi ooMerrev, ulesax tficynsnduo wsa aleedrt to eht cepnseer dna degere of edsnspeior, sbdeieat ,ileslutm dna vlaacrcsduiora neatimd.coi Teh lyeoogti or ltocoina fo teh eskrot dna the gdreen ro iamrlat attsus fo het esttnpia rewe otn sotisadaec twhi aecgsnh ni portkostes eslityuxa in setntpia in eth repents y."tdsu

Lnokgoi ta hte sneoutqi ainag, 'Im ienuggss eht etfigu"a dan dtficignfuli npgeesli nad cignro"acnetnt attmetsne wsa euppsosd ot eb a ecul rfo nspsoridee, yclaelpies iecns it rtsaedt arfet ish kres.ot l,osA on halicsyp ataimeoilsbrn essgtgu cintfnuigno is antcti dan thus anrcnutlo notcereis uodlw be erdveserp y.onlmarl ihsT si jtsu tpui.ds

ls3076  appreciate this kind of effort to look up journal articles but honestly this is not really what nbme answers is for... we should be able to get the answer from process of elimination/basic science concepts and not from looking up studies as we obviously can't do this on the test +  



 +0 
submitted by cathartic_medstu(28),
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Oiancgr DE: namrlo ,iliobd dseerdaec crnuatnol sretceoni

ePcgcyosnih E:D derseedac ioli,db nrmloa aclnourtn tcenrisoe

Got t.i




 +0 
submitted by ls3076(74),
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sI eersdaedc untaolncr nioerects not silsebpo due to eht rcgtiunnoyi bteeewn seont fo ssptmymo and erktos 2( mos vusres ?3) Arege hatt seteh qseouitsn are vrye avgue nad riftnu.sargt otN sreu eherw ot get a odgo apsrg no itsh eilma.tar




 +0 
submitted by cathartic_medstu(28),
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rtNocalnu neliep eseunetccm mtnsemeerau apahllghyo)(pr si a stet that seesamru tounsponeas lihnytg oeicersnt in ecirteel uncfydntiso ilyrarpi(m ererofdmp in a eelsp lotrab.yrao) s'It uufsle ofr fdfieteigntrian bewente naiorgc romf ongipcyshce erlieect ysductoinf.n

tnigteeV bsersiecd a byslpois ssrdeedep eitpnat g;&=t gopciyhnecs rteieelc dsnuifyt.onc niSec it is ton na raingoc sueca fo ,DE nncrulota etrecisno owdlu be roam.ln gniraOc eeiglisoto of ED lduinec gennurioec ro saacurlv.

idobiL atpr osucnfes me e.ehr bLodii esnma xluase riseed ro iateptp.e I asw ginnhkit sceni h'es gmconi in ot egt DE khcdc,ee it ctiesaind s'he apeitpte rfo xes is oguehn thta it mead mhi egt it .ecchk So bldiio doslhu eb o.rnlam yAn elp?h




 +0 
submitted by mattnatomy(43),
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rAenws = Dcaeedesr li;biod anrmol nactrloun neeiscotr

I ievleeb hwta ethy wree rtynig ot nidceiat ni isht sotiqnue asw hllcyPogcioas uxaleS utinsnofcyD a(ka - emerocnarfP eiAx.yt)n

In siht s,aec ti ta'wns so mchu eht noarmfeeprc ttah dwirero eht ma,n but he yma be so deofscu no his lhaeht sesius p(tso e)rts,ko taht eh si lbaneu to fromrep ayqeetluda. rho,eerfTe shi aartnul ildbio dwlou eb .eeerscadd r,eveoHw eseubac is't gysopicechn ap&m; not liihyo,spgco he lhodsu ltlsi vhea amnlor imhttneig enec.ritso

b1ackcoffee  Wouldn't pshychological SD have normal libido and just performance anxiety? +