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NBME 21 Answers

nbme21/Block 2/Question#7 (28.9 difficulty score)
A 50-year-old man with rheumatoid arthritis ...
Anemia of chronic disease🔍

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submitted by dr.xx(129),
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omAgn the msot letparevn ghtlmaceoio ibaenromtilsa in itptesna hwti icmoealohgtur soddresir aer het ianaem of cnrchio dsesaie ),(DCA a mlid aaienm atht is geeyralln ptiysaoa,mmct adn irno ifiedcyenc anem.ia

nI rcife-dnineocyi amiae,n hte BICT uoldw giherh atnh 004–405 mL/dgc uecesab eorsst ldwou be w.ol

tesatPni htiw RA iosacaclloyn ehva rcercnoutn rnoi cenidcyeif anmeia dna .CDA henW tihs ,urcsoc het olmnobiheg elelv lyasulu drpos to lweob 59. g,d/L dna the VMC is essl tnah 0.8


sympathetikey  Got the right answer too, but man, that whole "1 month after starting therapy" almost threw me off. +  
fkstpashls  all I do is put the wrong answer when I'm between two. Fuck +  

submitted by ragacha(14),
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AF 1208 agep 40.9 eiatcsodAs tiwh ofanmmtiialn (A,R LES, )DCK.

submitted by bartolomoose(3),

This one is fairly logical if you remember that bacteria LOVE our iron. So much so, that our body came up with a way around it. When an infection is detected by the body, it makes like a doomsday prepper and batons down the hatches.

"All the iron into the bones, quick (^ferritin)! Hide it from the intruders! Get those iron delivery trucks (ferritin) off the road (blood)!

with decreased ferritin comes a decrease capacity for binding iron in the blood

cooldudeboy1  i like the way to remember acd but there is no bacterial etiology in Rheumatoid arthritis is there? +  
the_enigma28  The body recognises chronic inflammatory states as infections +  
fatboyslim  Ferritin is not the "iron delivery trucks", that's actually TRANSFERRIN (transfers iron to liver and bone marrow). Ferritin is the STORAGE form of iron in the liver and bone marrow. In anemia of chronic disease, there usually is an inflammatory process going (whether infectious, auto-immune [as in this case of Rheumatoid Arthritis], or cancer). During inflammation, the body releases IL-6, which releases hepcidin. Hepcidin downregulates ferroportin channels in the gut and on macrophages; therefore you absorb less iron from the GI and iron is trapped in macrophages (ferritin) and cannot be used for RBC production. All this causes INCREASED FERRITIN, decreased TIBC (if ferritin goes up, TIBC goes down and vice versa), and decreased serum iron levels and TIBC saturation (the bone marrow will suck up all the serum iron to make RBCs because it cannot make use of the iron stored as ferritin). +7