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 +7  (nbme22#15)

This one was a little tricky. For this one the key is the low radioiodine uptake. This patient has high T4 and low TSH which makes sense in a hyperthyroid patient, perhaps your first thought is that this patient has Grave’s disease. However, in Grave’s your thyroid is being stimulated to make more thyroid hormone from scratch and as such would have an increased radioiodine uptake because the thyroid is bringing in the required (now radiolabeled) iodine. This is why it is not Graves (“release of thyroid hormone from a thyroid stimulated by antibodies”).

So if its not Grave’s what could it be? For this you’d have to know that Hashimoto’s Thyroiditis (also known as Chronic Lymphocytic Thyroiditis and is often referred to as such on board exams to throw you off) has three phases - first they are hyperthyroid, then euthyroid, then the classic hypothyroid that you would expect with low T4 and high TSH. This was the key to this question. The reason for this is that antithyroid peroxidase antibodies in Hashimoto’s cause the thyroid to release all of its stored thyroid hormone making the patient hyperthyroid for a short period of time. After this massive release of thyroid hormone, the antibodies make them unable to make new TH and therefore they become euthyroid for a short period and then hypothyroid which you would expect! Since they can’t make new TH, the thyroid will not take up the radioiodine and therefore there will be low radioiodine uptake. Hence, “release of stored thyroid hormone from a thyroid gland infiltrated by lymphocytes.” aka “Lymphocytic (hashimotos) thyroiditis”.

I think “release of thyroid hormone from a lymphomatous thyroid gland” is referring to some kind of thyroid cancer in which case you would expect them to be describing a nodule on radioiodine uptake.

​Summary video here and also a great site in general: https://onlinemeded.org/spa/endocrine/thyroid/acquire

aesalmon  pg 338 of FA lists it under hypothyroidism but it does present as transient hyperthyroidism first
hyperfukus  yep that was the key! Goiter is "HOT" but the remaining answer choices were still kind of bleh D was distracting the hell out of me i spent so long to convince myself to pick C and move on
hello  Pasting nwinkelmann's comment as an addition: Choice "D" is wrong b/c "lymphomatous thyroid gland" = primary thyroid lymphoma (typically NHL, which is very rare) or Hashimoto's thyroid progression. Hashimoto's thyroiditis = lymphocytic infiltrate with germinal B cells and Hurthle cells, which upon continued stimulation, can lead to mutation/malignant transformation to B cell lymphoma. Both of these present with hypothyroidism with low T4 and high TSH (opposite of this patient).

 +6  (nbme22#32)

Good fact to commit to memory: you lose bicarb in the stool (hence why diarrhea causes nonanion gap metabolic acidosis), and especially lose potassium with laxative abuse (as mentioned in the question stem). https://www.uptodate.com/contents/acid-base-and-electrolyte-abnormalities-with-diarrhea

sbryant6  I'm going to go take a big bicarbonate poop now.
happysingh  i would suggest that you look into it a bit more. Why ? Had an nbme question (which confused the shit out of me) cuz, Bluemic Pt. who was abusing Laxatives (had the up & down arrows) and this is what it gave : Laxative Abuse — Metabolic Alkalosis :   ↓K+     ↑Cl-                   ↑pH    ↓HCO3- so one of the points of distinction IS the increase in Cl- with laxative abuse (vs. vomiting, which was a knee-jerk reaction when i hear bulimia)




Subcomments ...

submitted by medstudied(2),

Why is the correct answer chi-square test? I get that it’s used for categorical variables but we’re comparing prevalence percentages. Is that considered categorical?

liverdietrying  You’re looking at two categorical variables, Caucasian vs. AA and HTN versus normotensive. So you’re still using Chi2 to analyze. +1  


submitted by iviax94(5),

There have been a couple of questions about this topic on the newer exams. I’ve been answering by equating libido to testosterone levels and nocturnal erections to health of vasculature (atherosclerosis or not). Is this correct?

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. +6  
_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? +  
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. +1  
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. +  
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. +  


submitted by iviax94(5),

I was between hypokalemia (due to diarrhea) and hypercalcemia/hyperuricemia (since sweat is hypotonic and would cause hyperosmotic volume contraction). I didn’t have a great way to decide between hyperCa/hyperuricemia so I figured they wanted hypoK. Is there a better rationale for why the hyper answers are incorrect?

liverdietrying  I think you over-thought this one a little bit with the hypercalcemia/hyperuricemia. Good fact to commit to memory: you lose bicarb in the stool (hence why diarrhea causes nonanion gap metabolic acidosis), and especially lose potassium with laxative abuse (as mentioned in the question stem). https://www.uptodate.com/contents/acid-base-and-electrolyte-abnormalities-with-diarrhea +1  
w7er  Basically they are asking about electrolyte distrubance that cause collapse mainly due to hypokalemia from laxative abuse because diarreha cause hypokamlemia and also cause incrase in renin angiotensin sytem which will further cause hypokalemia resuling cardiocascular colapse :) +  
hyperfukus  i thought the hyperuricemia thing too but i wasn't smart enough to think they wanted hypokalemia like u :( +  


submitted by iviax94(5),

There have been a couple of questions about this topic on the newer exams. I’ve been answering by equating libido to testosterone levels and nocturnal erections to health of vasculature (atherosclerosis or not). Is this correct?

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. +6  
_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? +  
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. +1  
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. +  
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. +  


submitted by iviax94(5),

CT shows mass on the left side of his abdomen and you’re told it’s intussusception. Asks which part of the GI tract is most likely to cause the pain. I immediately looked for ileocecal junction ... not an answer choice. Why is the answer jejunum (vs. duodenum)?

liverdietrying  The picture is key here. You’re right that ileocecal is most common, but ileo-ileal and jejuno-jejunal are the next most common (I think I might just know this from having done clerkships already, not sure). Ileo-ileal isn’t an answer, so that rules that out. Look at where the arrows are pointing in the picture as well. Its on the L, ruling out appendix and cecum. And the slice is not at the level of the duodenum, ruling out that answer. So by process of elimination based on the picture you could get this one too. +2  
dr.xx  Duodeno-duodenal intussusception is a rare because of the retroperitoneal fixation of the duodenum. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529645/ +1  


submitted by airhead5(2),

The answer is carcinoma of the breast. I get that, but I’m having trouble figuring out which Carcinoma of Breast it is. I’m stuck between DCIS, and Invasive Ductal Carcinoma. I’m leaning towards Invasive Ductal Carcinoma, just because it’s (1) most common and (2) the mass with irregular margins in clusters sounds like it could be ‘stellate infiltration’, seen in Invasive Ductal Carcinoma. But I’m not sure. Can anyone help?

liverdietrying  There is not enough information in the question stem to determine what kind of cancer it is. You would need a biopsy and histology information to determine that. However, this is definitely not DCIS since there *is* a mass. DCIS usually just shows up as small microcalcifications on XR (I’d google an image so you can see it). All the words they use here describe an invasive cancerous scary mass -- what kind of cancer can’t be known until they biopsy it! +  


submitted by airhead5(2),

Does anyone know the disease they are talking about? I was thinking lupus which makes sense with the answer, but i can’t find anything on anterior chamber of eye and choroid plexus.

liverdietrying  It's lupus, all the symptoms listed are classic especially the serositis. Anterior chamber of the eye = uveitis. Choroid plexus = cerebritis. For a great overview, check out this (free) video: https://onlinemeded.org/spa/rheumatology/lupus/acquire +1  
in_a_pass_life  I think this was reactive arthritis, not lupus. Choroid plexus not just in the brain, also in eye (can’t see, can’t pee, can’t climb a tree). Mechanism of reactive arthritis is immune complex deposition, per UWorld, which was correct answer. +2  
trichotillomaniac  The inside of the eye is divided into two chambers: the anterior chamber and the posterior chamber. Both chambers contain fluid, and when there’s inflammation in the eye, a specialist can often see inflammatory cells in the fluid. https://www.hss.edu/conditions_eye-problems-lupus.asp +  
trichotillomaniac  I agree that this is Lupus after doing some more research! +  
nwinkelmann  I find this article describing the SLE ocular manifestations, including uveitis and cerebritis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908056/ Also this talks about the lupus cerebritis (choroid plexus inflammation): https://en.wikipedia.org/wiki/Cerebritis +  
medulla  every time I read about Lupus there is something new!! +