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NBME 24 Answers

nbme24/Block 2/Question#1 (51.6 difficulty score)
A 73-year-old woman has had easy fatigability ...
Failure of conversion of N5-methyltetrahydrofolate to tetrahydrofolate🔍,📺

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submitted by yex(103),
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nccgAiodr ot nGjal:o "B21 oncbaailm)( ash btcaol ni it. liiratcgunC mfro of ftlaoe si mrtftoth.leaeyydthealro Proepsu of cmloanabi 2)B(1 is ot taek eht yltemh gpuro fof fo ytefmattrlahldtrhyoeo.e nehT sit’ dcalel aoeryfelrtd.ohtat If uoy ’dtno get eth ehmytl uogrp ffo of ,oeflta oyu llwi ont maek .AND oS, if yuo are 1B2 edf, yuo tc’na tge hte mlyteh pougr ffo nda tonnca maek ND.A fI you are dfe in etol,fa uyo ’cant kema NAD."

misterdoctor69  lmao +  

pic of the methionine/folate cycle:

+2/- hungrybox(1051),

submitted by syoung07(30),

would have been real neato if they threw in a hyper-segmented neutrophil

submitted by lsmarshall(417),
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lgtuhohA hs'onCr may ehva usler,c fls,suait and ;lgbndiee it asluluy dose ton cseua onir idfceeicyn anmiae nda has less lebidneg htna C.U "crStlrtuau isremaatilobn of eht almerint ei,lum uhsc sa hCnro sseeida and lsuircag tir,ncseoe can ucsae cradesdee orsitnboap fo nivtmia 2"B1. - Fistr Aid reneaGl nslieriPpc

submitted by lispectedwumbologist(109),
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hyW wolud ti not eb niamae fo rchnico easieds ithw srdceedae emrsu fnerrtinsra cn?rtoticnanoe

lispectedwumbologist  Nevermind I'm stupid as fuck I see my mistake +2  
drdoom  be kind to yourself, doc! (it's a long road we're on!) +21  
step1forthewin  Hi, can someone explain the blood smear? isn't it supposed to show hypersegmented neutrophils if it was B12 deficiency? +1  
loftybirdman  I think the blood smear is showing a lone lymphocyte, which should be the same size as a normal RBC. You can see the RBCs in this smear are bigger than that ->macrocytic ->B12 deficiency +23  
seagull  maybe i'm new to the game. but isn't the answer folate deficiency and not B12? Also, i though it was anemia of chronic disease as well. +  
vshummy  Lispectedwumbologist, please explain your mistake? Lol because that seems like a respectible answer to me... +9  
gonyyong  It's a B12 deficiency Ileum is where B12 is reabsorbed, folate is jejunum The blood smear is showing enlarged RBCs Methionine synthase does this conversion, using cofactor B12 +1  
uslme123  Anemia of chronic disease is a microcytic anemia -- I believe this is why they put a lymphocyte on the side -- so we could see that it was a macrocytic anemia. +3  
yotsubato  Thanks NBME, that really helped me.... +1  
keshvi  the question was relatively easy, but the picture was so misguiding i felt! i thought it looked like microcytic RBCs. I guess the key is, that they clearly mentioned distal ileum. and that is THE site for B12 absorption. +6  
sahusema  I didn't even register that was a lymphocyte. I thought I was seeing target cells so I was confused AF +  
drschmoctor  Leave it to NBME to find the palest macrocytes on the planet. +5  
zevvyt  so i guess size is more important than color cause those are hypochromatic as fuck +  
yesa  The NUCLEUS of a lymphocyte should be the same size as a normal RBC, which is not the case here. Under normal circumstances RBCs are not as big as lymphocytes, so this is truly extraordinary = megaloblastic anemia. +  

submitted by sunshinesweetheart(82),
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tamoccriyc maniae nse(e ni oodlb eamr)s = RBC epcssuorrr anc wogr tub tno diveid

aolv ryactsceom esne( in odlbo mr)esa = eliagaloctmbs inamea f(i ehty tnod' whos rutlenpohi nsohyetpatnergmie)

1B2 sah lcnorugieo mtmpoyss dna wlo tmlinhloaymce caid lhewi ltfaeo yiceencfdi sode ont

ofaetl is ebsdorab in jmu,jeun 21B in uieml

sasec u fo 2B1 ceydienifc = eicniurpso ,eminaa yeota,smrgtc lleia etreni,soc hifs ar,motpew vnmaeigs

)D uelirfa of THFRM -;&tg- HTF iav( hrafreyastnsmltee = 1B2 yiniefeccd dna iccyaorcmt enaiam

)B 6PDG dyfniiecce = ncrtooiycm bseaecu of nric CBR stuotnidecr; pt dwoul hosw arrlaacnutvis hossyimel xs crieiatedptp yb na teovxadii rsrtssoe

)C ogrnehiopporynpot sxaodei efccniidye = iyrotimccc aneaim bsceaeu of wlo emeh yssehsnti

A) rcde saeirrtfnrn = high inftrrie = eamian fo hniccor eeiadss = iccyoirctm ianmea buescea fo wlo nroi

submitted by krewfoo99(93),
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cflio dica wneh ti nesrte teh dboy is in the ofrm fo rmeltlhhyrttaoteyaoefd T(FH htl.mtdeya)e It sotndae ist ymetlh gropu ot vantiim 1B2 to boecem THF hte( eivcat mrfo iwchh sa a ADN rsu)coerp.r eh T natmiiv 1B2 whti tis tlyhme oprgu osge on ot imebcno ihtw cthyeomneio to mrfo ieotem.ihnn