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 +2  (nbme19#15)

the hallmark of meningioma is its relation to a meningeal surface hence relation to sulcus

cbreland  I really wanted to pick GBM/astrocytoma here +

Subcomments ...

submitted by cassdawg(1179),

TL;DR: This is Ewing sarcoma because it is a young boy with small blue cell bone tumor in the diaphysis of the femur

Ewing sarcoma is a malignant bone tumor common in young boys <15y.o. typically found in the diaphesis (middle) of long bones (particularly femur) or pelvic flat bones. It is a small blue cell tumor, meaning the descriptor of small, uniform, hyperchromatic cells with high nucleus:cytoplasm ratio. It also has an "onion skin" periosteal reaction in the bone (described as tissue surrounded by concentric layers of reactive bone in the question). Not mentioned is the association with t(11;22). [FA 2020 p 464]

Why the others are wrong:

  • Chondrosarcoma is a tumor of malignant chondrocytes (catilage) and found mainly in the pelvis, proximal fever, and humerus
  • Eosinophilic granuloma is is a rare, benign tumor-like disorder characterized by clonal proliferation of Langerhans cells and the most common varient of Langerhans cell histiocytosis.Would likely say something about Birbeck granules in the stem and would have associated symptoms such as rash [FA 2020 p434]
  • Multiple myeloma is a plasma cell dyscrasia [FA 2020 p431] with overproduction of (typically) IgG. Characteristics include CRAB - hyperCalcemia, Renal involvement, Anemia, Back/Bone pain due to punched out lytic bone lesions (typically of the spine)
  • Nephroblastoma/Wilm's Tumor is the most common renal malignancy of early childhood and presents as a flank mass [FA 2020 p 606]
  • Osteosarcoma (or osteogenic sarcoma) is a primary bone tumor common in men <20. It is typically found in the metaphysis (tips) of long bones. Histology shows pleiomorphic osteoid producing cells. On X-ray you would potentially see a Codman triangle (elevation of periosteum) or sunburst pattern
  • Small lymphocytic lymphoma is essentially the same thing as chronic lymphocytic leukemia. It is considered a non-Hodgkin lymphoma of B-cells and the most common leukemia of adults (as CLL). Smudge cells would likely be seen on peripheral blood smear. It would not likely present as an osteolytic lesion and is unlikely in children. [FA2020 p432]
cbay0509  thank you +  

submitted by aliyah(30),
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heT hrgti es'ey tnefefer evnres are gnrwok,i as lfte eey lmuiaotnsti usacse a ncageh ni teh ritgh .Teyhe e rghit eye copit .n gmdeaa sascue st'i rtenfafe n. to eb .meaagdd It cn'ta arycr nfio ot ,ibnra so girht nad tfle eye nat'c rtcnicsto to tlg.hi

icedcoffeeislyfe  APD--> swinging flashlight test, light in the AFFECTED eye will result in dilation of both pupils inappropriately +1  
cbay0509  thank you +  
nbme_123  Can someone please explain why it cant be the Right Edinger Westphal nucleus? +  

submitted by drdoom(892),
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lbnIiytia ot tinaanim an orntceei = reeeltic ynocifsdutn. oS nwo eth eousqnti is ?W"hy"

Feuagit, fdyuilcift ie,pnsleg tyifucifdl itcognnaentrc is rsngitta ot duson ekil pisdsoeern. ifulfyDitc" cttnnncegor"ia higtm eb tedriertepn as aiimdrep vxceueeit cfinunto or eth sbninginge of varsatercu-ealld emdantie t(dmaneei etdlare ot slmal utb sruumnoe rrebelac fst,ci)nar ubt no Setp 1 mtdnaeei wlil be tlabatn .,ei(. slo"t shi way "om,he gw"denna",ir c..e)t

eprDenisos is tlalucay onmomc aftre a ttadiglibien evtne ielk oksret, sa ouy hmgti e.pecxt tihW spisrdnoee mseoc a olss of uxsale esnrttie dan tsedeitha—r is cdsaeedre idloib.

One nac keam the rtnuamge ttah a alsarcv"u pteain"t mithg heav seom issseu hiwt ish peis"p" ,olcrsrseoriats(ei caaptprymcstthehpiiy/estama tnifyndc)suo nd,a fro this srao,ne onutlrcna onrcetie suohdl be secareedd; btu toen tath hgtnino is neonmtdie oatbu ngontl-dngais scvalura esdiesa on( xh of eenytph.nosir)

As a utersl, eth esbt rswaen cocehi heer is C. boLd(ii eeesradcd btu tnoucrlna ecesiornt lor) heT gib tosiqeun I heva is, how teh kche dose tshi gyu kown e'hs radh nehw h'es ?ae!l!eps p:

cbay0509  thank you +1  
ilikedmyfirstusername  there are several UWorld questions about psychogenic ED with the answer being normal libido and normal nocturnal erections, idgi +13  
djeffs1  Yeah NBME says its C, but I still think with a recent stroke you can't bank on normal nocturnal erections... +  
drdoom  @djeffs nocturnal erections happen at the level of the spinal cord (S2–S4)! a “brain stroke” (UMN damage or “cortical damage”) would not kill your ability to have nocturnal erections! +  
drjo  fatigue, difficulty sleeping and concentrating could be depression or hypothyroidism both of which can cause decreased libido +  
jurrutia  @djeffs1 when you say NBME say's it's C, how do you know that's the official answer? Did NBME post the answers somewhere? +  
djeffs1  in the versions I purchased from them they highlight the correct answer in the test review +1  
shieldmaiden  For me the keyword in the stem is "maintain"; he can maintain an erection, therefore nocturnal erections must be normal. Libido, on the other hand, is psychologically driven, so if he is depressed (trouble sleeping, concentrating, fatigue, recent major health problem) then the strength towards any kind of desire, including sexual, will be low +  

submitted by ajguard26(41),
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hsiT paetitn esptsnre hwti saclisc urepp otrmo nroenu nlseio ostysmmp: neaew,ssk efl,aeeryxirhp nda eeedcsrad tanois.sen worHeve, het qistuoen etstas ehs ont"cna llet tehhwre ehr letf targe oet is redsai or pede"dsrse ewnh ehr ysee era dslc,oe ihwhc yma kema yuo sdceroenir adn tkhni ereht mya eb soem iororeppptcvie seusis tyeh rea tnyrig to inth .ta sihT si otn eht cllspEeiay noce yhet ietonmn eethr aer no horte isaitbmanelro i.e.(, no upper mbli briltmoasneai ro hgrti dside iteorm.)nbsaali fI hits si het aes,c heter is on madage ot het attcsr at lal (wchhi era still erecdisndo .)NMU

Tr,feeeorh the eagdam si yelupr ortom dan nsresoy ni teh tlef gl,e hhicw is no het ediaml pestac fo hte tonafrl nad aelapirt eblso ele.cvtersipy This area is upiepsld yb hte raernito rblcaere y.rtare

issamd1221  contralateral deficits +  
cbay0509  thank you +  
flapjacks  I think her 60 pack-year history suggests possible PAD and therefore loss of proprioception in the lower extremities, leading to an unfortunate distractor +  
an_improved_me  I don't understand why you would consider the propioceptive deficit a distractor... doesn't the DCML (which carries propioceptive information) project to the primary somatosensory cortex (via the VPL?). In this case, a lesion to the right anterior cerebral artery, which supplies both motor and sensory information to the lower limb would lead to somatosensory, propioceptive, and motor deficits. +  


In heparin induced thrombocytopenia IgG Ab are developed against platelet factor 4 leading to thrombosis and thrombocytopenia

FA2020 pg 436

cbay0509  thank you +  

submitted by cassdawg(1179),

This is G6PD deficiency. (FA2020 p422)

G6PD deficiency causes a hemolytic anemia when individuals are exposed to antimalarials due to the increased oxidative stress. This is due to the deficiency in replenishing NADPH which is necessary to replinish reduced glutathione which aids in quenching free radicals.

cbay0509  thank you +1  

submitted by ajguard26(41),
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hocinCior ililv nigmslpa si eth kating fo itgcene mteliaar itnwhi in the cnhiooric livli fo eht tlaaecnp. nCioichor pnsgilma is oned hnew a tpenita is ta gihh srki orf calmhroomos rbalinetmosai ver(uspio pso. stest, 53oy ro re,ldo yilfma x)h. giurnd eth -1130 wkese of agcnrype.n

fnniedoC lcapenlta iscasommi ruestsl ehnw eht .VS..C stingte smoec ackb abck ghsowin a riost,ym btu lla uqunbetess gsitnet dna( the eftsu lt)iefs eahv amlorn hosamrlomco n.stouc sThi yma be deu ot hterie a pcsitaortolhb tautmio,n ro by ocimts"ir re,c"eus in wichh oiimrcts elscl atht ewre eppusosd to be ni eht sufte ear infocden ot het aptnlcea to petvrne an aomlanbr usef.t

cbay0509  thank you +  
shakakaka  Why It's unreadable.. +2  
randi  unfortunately you have to have an account to unscramble most responses +  

submitted by shadowbox(12),
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neSci het sfa'hter lbniigs si fad,tfeec we wkno ttha the htesa'rf atsrpne era htbo reirarcs. aTth measn het islbsoep gnpesoeyt fo eht efrtha are A,A ,Aa ,aA or .aa

We wkon hte fareth is eufcd,nefat os that masen eh toncan be ,aa and sumt eb ieehtr AA, ,aA ro .aA

niecS eethr era oynl 3 rfefdenti yetenpsgo eh udlco h,aev itwh 2 fo meth ignbe rarecri syopeeg,tn ehetr si a /23 otplrbiyaib he si a carrre.i

oS we noatib the tbaypliibro fo eth rtfaeh spisnga no a esiesrcev lleeal sa /32 tbryoipa(lbi fo gebni a )rerirac x 1/2 prbiy(atbiol of siganps no a escreevsi elella fi eh is a rcie).arr eTh /32 is not nrealtve ot the yapbrtiblio thta het remtoh si a cirrear.

eW konw hte eryncuqfe fo ftdeefca svniiaduidl in teh appilounto ta large is 0,1040/0 (^2)q=, os =20.q0/1

,Pq+1= so 1209=0p/9 dna =192/2p001q220/9().)0(

To kame mciiniuattlpol rieeas we msaseu 090/91,=21 :so

/=1020202p*=1)/(1q0 &--;gt tihs is eht careirr nycuefrqe ..,.aka( gt)toeeezshory in hte i,lptonauop wchih ew acn samesu rfo hte emthor.

oS, ot erwsna het nieetr uqtsoien ew yitupmll teh ptiaobrybli tath eharft si a rcriare ()23/ adn spseas no teh aellle (/2)1 emtsi hte roiilatbybp atth omrthe si a aricrre 00/(1)1 dan easssp no eth lalele )1/;2( itgtnpu it all teotgher we hve:a

/21*/))3*/10(0)1/1((2*2() = 01202/ = 1060/

cbay0509  thank you +  

submitted by hayayah(1080),
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llFiimaa oouamenadts lsioyopsp is an oaumaotls nnotdima m.utnaito hdonasTsu of opypsl rsiae atgntsri traef byptreu; cnc;aopnoli aywsal nvsoivel umretc. cpoiacrtPhly clymooect or esle 001% opsesrrg ot C.CR

smtouloaA ndomniat esasseid ahv,e no graaee,v 05% enchca of engib saepsd odnw to orfns.gpif

sympathetikey  I would say this is Lynch Syndrome (APC is usually thousands of polyps) but lynch syndrome would generally have a family history of other cancers as well, so you might be right. Either way, both autosomal dominant so win win. +2  
smc213  uptodate states: Classic FAP is characterized by the presence of 100 or more adenomatous colorectal polyps +  
dickass  @sympathetikey Lynch Syndrome is literally called "Hereditary NON-POLYPOSIS colorectal cancer" +9  
fatboyslim  I think this actually is Lynch syndrome. Lynch syndrome can also develop colonic polyps but not nearly as bad as FAP. FAP has so many polyps you can't even see the normal mucosa. If you Google Lynch colonoscopy you can see that they develop a few polyps. +  
rockodude  I forgot it was AD inheritance but regardless at the time I was confused because APC is a tumor suppressor so it needs two hits. I guess AD inheritance and then you need another hit to develop CRC kind of like familial retinoblastoma or li fraumeni syndrome +