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Comments ...

 +0  (nbme21#2)

Could anyone give an example of what diseases would best match the other answer choices?

vonhippelindau  Leprosy is a noncaseating granuloma fyi. I found that granuloma with suppuration can be caused by blastomycosis according to Robbins (pg 710): “In the normal host, the lung lesions of blastomycosis are suppurative granulomas. Macrophages have a limited ability to ingest and kill B. dermatitidis, and the persistence of the yeast cells leads to continued recruitment of neutrophils. In tissue, B. dermatitidis is a round, 5- to 15-μm yeast cell that divides by broad-based budding. It has a thick, double-contoured cell wall, and visible nuclei (Fig. 15-38). Involvement of the skin and larynx is associated with marked epithelial hyperplasia, which may be mistaken for squamous cell carcinoma.”
usmleuser007  Pyogranulomatous Inflammation An inflammatory process in which there is infiltration of polymorphonuclear cells into a more chronic area of inflammation characterized by mononuclear cells, macrophages, lymphocytes and possibly plasma cells. Actinomyces sp. is gram-positive, acid-fast–negative filamentous bacteria that cause pyogranulomatous infections in dogs, cats, cattle, goats, swine, horses, foxes and human beings.

 +1  (nbme22#46)

how do you narrow down that testosterone increased hemoglobin concentration? just a random fact to know? i put alkaline phosphatase because i figured increased testosterone will increase bone growth and ruled out prostate-specific antigen bc it’s a woman.

hysitron  I guessed this one cause men have a higher hemoglobin than women.
notadoctor  High levels of testosterone will result in amenorrhea. I guessed that since she's not menstruating she will not be losing blood and therefore hemoglobin. Therefore her hemoglobin levels will be higher than expected.
meningitis  It kinda makes sense knowing testosterone causes catabolism so I was in between Alkaline phosphatase and hemoglobin...
enbeemee  isn't testosterone anabolic?

 +2  (nbme22#37)

does anyone know what A, B, C and E are pointing to? I figured D is substantia nigra since it's the correct answer.

upstairs_bumblebee  A/B - i think both of these are just thalamic nuclei; C -> STN; D -> substantia nigra; E -> hippocampus

 +2  (nbme22#33)

I get she doubled her levothyroxine dose because of fatigue. I get that TSH is decreased. But why is free T4 decreased and free T3 increased? Wouldn’t both free T4 and free T3 be increased?

lnsetick  she doubled her triiodothyronine not levothyroxine, so she took a bunch of T3 -> feedback inhibition of TSH and therefore decreased T4
oznefu  D’oh didn’t even read that just assumed it was levothyroxine. Thanks!

 +0  (nbme22#15)

What are the words that point to Carcinoma rather than Fibrocystic or Fibroadenoma or Fat Necrosis (not an answer)?

Those can have masses and calcifications right? Is it only the irregular margins?

mnemonia  Fibrocystic changes doesn’t technically encompass sclerosing adenosis, which is the one where you would get calcifications. Cysts and fibrosis don’t usually present with calcifications. Fat necrosis I’m sure they would give history of trauma in the stem.
mnemonia  Calcifications = fat necrosis, sclerosing adenosis, and DCIS/IDC. Microcalcifications specifically I would venture to say is a buzzword ductal carcinoma specifically. Either way, of these 3, only cancer is an answer choice.

 +1  (nbme22#27)

I’m having trouble understanding why this is a better choice than Paget disease, especially with the increased ALP?

zelderonmorningstar  Paget’s would also show some sclerosis.
seagull  ALK is increased in bone breakdown too. Prostate loves spreading to the lumbar Spine. It's like crack-cocaine for cancer.
aesalmon  I think the "Worse at night" lends itself more towards mets, and the pt demographics lean towards prostate cancer, which loves to go to the lumbar spine via the Batson plexus. I picked Paget but i think they would have given something more telling if they wanted pagets, histology or another clue
fcambridge  @seagull and aesalmon, I think you're a bit off here. Prostate mets would be osteoblastic, not osteolytic as is described in the vignette.
sup  Yeah I chose Paget's too bcz I figured if it wasn't prostate cancer (which as @fcambridge said would present w/ osteoblastic lesions) they would give us another presenting sx of the metastatic cancer (lung, renal, skin) that might point us in that direction. I got distracted by the increased ALP too and fell for Paget :(
kernicterusthefrog  @fcambridge, not exactly. Yes, prostate mets tends to be osteoblastic, but about 30% are found to be lytic, per this study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768452/ Additionally, the night bone pains point to mets, and Paget's is much more commonly found in the cranial bones and appendicular skeleton, than axial. This could also be RCC mets!
sweetmed  I mainly ruled out pagets because they said the physical examination was normal. He would def have other symptoms.

 +0  (nbme22#6)

I get that the answer is correct for a reversible injury where there is cell swelling because of the increased intracellular Na+ and Ca2+ due to impaired Na/K and sarcoplasmic reticulum activity ...

But if there are increased cardiac enzymes in the blood indicating cell death and membrane damage, wouldn’t the intracellular electrolytes be low since they are released into the blood?

lord_voss  troponin = irreversible injury and membrane damage -> high extracellular concentration of Na+ and Ca++ causes both to move into cell through damaged membrane and high intracellular K+ leaves the cell
rogeliogs  Question is asking about the changes in the myocardiocytes and my second interpretation was that they are asking the changes before they "rupture" and liberate their content in the blood producing increase enzymes in the patient. Therefore because is a ischemic process = reduction of O2 = low ATP = impairment of Na/K ATPase = increase Na-decrease K intracellular = block Ca/Na exchanger = increase Ca intracellular. the same effect as digoxin




Subcomments ...

submitted by mcl(169),

This image is useful. Note that the stain used makes myelin appear dark.

Vignette is typical for Parkinson's disease. Area D is the substantia nigra.

oznefu  Oh nice! Thanks! +  


submitted by oznefu(7),

I get she doubled her levothyroxine dose because of fatigue. I get that TSH is decreased. But why is free T4 decreased and free T3 increased? Wouldn’t both free T4 and free T3 be increased?

lnsetick  she doubled her triiodothyronine not levothyroxine, so she took a bunch of T3 -> feedback inhibition of TSH and therefore decreased T4 +3  
oznefu  D’oh didn’t even read that just assumed it was levothyroxine. Thanks! +1