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 +0  (nbme22#12)

Why not PGI2 by way of ASA? Especially given other answer choices of proteins C + S: doesn't warfarin also suppress these?

imnotarobotbut  Protein C and S are ANTI-thrombotic, so although Warfarin does decrease them, they wouldn't decrease the patient's risk for thrombosis
epr94  the question ask "suppression" of which one will decrease risk of thrombosis if you suppress C and S which and anti-thrombotic you get thrombotic

 +0  (nbme22#46)

Somehow I was able to convince myself that increased testosterone --> decreased estrogen --> decreased negative feedback on LH/FSH secretion --> increased FSH. Does anyone care to explain why this logic is wrong? Thanks :)

btl_nyc  The increased testosterone is metabolized by granulosa cells to estrogen and by adipose tissue into estrone. Both feed back on the hypothalamus to inhibit FSH & LH secretion, but FSH is much more sensitive to feedback inhibition than LH, causing an increased LH/FSH ratio.
impostersyndromel1000  @sup, i did the same thing. Had no idea testosterone and androgens can increase epo




Subcomments ...

submitted by yotsubato(255),

Why cant this be laxatives? Both would cause metabolic alkalosis with hypokalemia... ?

sup  Laxatives would cause an anion gap metabolic acidosis due to loss of bicarbonate in the stool. You would see hypokalemia though as seen in this question. +  


submitted by oznefu(7),

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. +1  
seagull  ALK is increased in bone breakdown too. Prostate loves spreading to the lumbar Spine. It's like crack-cocaine for cancer. +1  
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. +5  
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. +2  
cathartic_medstu  From what I remember from Pathoma: Metastasis to bone is usually osteolytic with exception to prostate, which is osteoblastic. Therefore, stem says NUMEROUS lytic lesions and sounds more like metastasis. +1  


submitted by hello(62),

Patient in hypovolemic shock - the clues are low BP and COOL skin. Hypovolemic shock is caused by fluid loss.

The patient has decreased preload b/c of fluid loss, i.e. there is decreased blood volume returning to heart --> thus decreased preload.

endochondral   why not dec SVR? +  
sup  @endochondral w/ hypovolemic shock you would see increased systemic arterial resistance as arteries will constrict to try and bring BP back up. +  
eacv  @endochondral dec SVR it typicaly of septic shock. +  


submitted by medschul(11),

I can get behind splenomegaly, but what is the disorder?

sup  Felty syndrome, an extraarticular manifestation of RA. Symptoms include a triad of RA, splenomegaly and neutropenia. It's in FA, you just have to squint (look at the fine print under the RA vs OA table in the MSK section). +3