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NBME 22 Answers

nbme22/Block 2/Question#7 (68.5 difficulty score)
A 66-year-old man comes to the physician ...
Libido: decreased;
Nocturnal erections: normal
🔍

tags: erections penis libido 

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 +5 
submitted by paperbackwriter(112),

SPOILERS FOR NBME 21 -- DON'T READ AHEAD IF YOU HAVEN'T TAKEN 21

After getting it wrong (because of the NBME 21 Q), I understood it like this:

– Libido is a long term state, meaning your libido could be fine, but anxiety in that MOMENT might cause psychogenic ED

– This guy has some classic SIG E CAPS criteria going on: fatigue (energy loss), sleep disturbances, concentration problems

– It says he hasn't been able to maintain any erection (vs NBME 21 guy that was able to masturbate (his long term sex drive was OK) but had performance anxiety in the moment)

Therefore, lack of sex drive fueled by depression --> low libido, but physiologically nothing wrong with him --> nighttime erections

trump2020  Bless you for including the spoiler warning +2  
kernicteruscandycorn  @paperbackwriter: sick name and reference +  



 +3 
submitted by iviax94(7),
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erTeh evha nebe a clpoue of tenisousq tbauo iths opitc on hte rween .mxesa ’eIv eenb innsewrag yb qugtiena idboil to steornseotte eselvl nda latncuorn tcrseieon ot ehhalt fo cvsareuluta slrehoaeo(sctsir or nto). sI ihts ?oterrcc

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. +28  
_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? +5  
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. +4  
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. +2  
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. +4  
pg32  I can't remember exactly but I swear the question on NBME 21 the guy's wife had died as well...? Or they had gotten divorced? Either way, he had some psychological baggage as well, but his libido was still normal, and the explanation was that his testosterone would be fine regardless of his depressed mood. So I went with that logic here and missed this question. I don't understand how I am supposed to gauge someone's libido based on vague hints at their mood, especially when in one exam mood does not decrease libido and in the other it does. +1  
drzed  @pg32 bro spoilers +2  



 +2 
submitted by elf16(2),
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oHw si hsit efitndfer fomr hte usiqento no NMEB 12 ni hhciw a 86reya- dlo nma salo dah scegpciynho ED? But het rwsane wsa nlmrao idlibo dan lncnoruta eot.seicrn

toxoplasmabartonella  In that case, his testosterone was normal and he had no signs of depression. The stem did say his wife passed away few months ago, so i personally chose low libido, but whatever. +  



 +1 
submitted by adong(97),

Pretty much if they can masturbate or get it up alone in any way their nocturnal tumescence should be normal meaning that their innervation and reflex pathways are all intact. Libido aka sex drive from what I’ve seen so far is altered by depression. So like in the question on NBME 21 the stem stated that screening for depression was negative which is why libido would also be normal in this case. If there’s ever a Q with a depressed guy and normal lab values and physical exam, most likely gonna be decreased libido with normal night erections - courtesy of /u/diffuseaxonalinjury




 +1 
submitted by nwinkelmann(292),
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So, I gotuthh ihst onqtuise wsa epusr gaveu adn otn er.t.a.g tath ibnge said, gvnahi ettngo it ngwro dna tno erylal ihgnva a ogdo laatpxonnei rof teh aesn,wr I ddi a lteilt hcreeasr dan nuofd shti ailre:tc 0taST.j:a/1o./opsh.spl./4da50h7/g31d.01iuwwt1r/r.R/of1n1w.6

sTih was eht nami :nnuooscilc hT"e rsteuls of hte senpetr duy,st edima ta iasnesgss hte tsefecf fo otersk on suxale tnc,ogfunini veaerl a sfiicgtnnia ecndlei in bodiil, claoti uqnrce,efy ueaslx ,alsrauo nad otnisftcaais iwth auexsl efli ni bhot trkeso tetsapin nda rheti ssup.ose The rneepst rsustel laos noamttesrde thta ersdroisd of elxsua ftincsnou aer ostm initfacnylsig tecdssoaia whti usoriva syhcclaopsio scofrat, usch as atitens’p arnleeg tdetuait tadrwo ,isxaeyutl faer of eocpmi,tne adn iiylatb ot issucds xa,etuliys as wlle as hwit het regede fo stroepskot ninuflcoat .iilbdysati v,roreoMe axelus cysndnotifu saw leadtre ot teh esenperc and eeredg fo osrsdineep, tiesebad u,ltsilem dna vuarcdolcrisaa .nidtaoicme heT yitegolo ro lnoioatc of the sortek dna eth dgrnee ro iaalrtm ttauss fo teh taeitsnp ewre otn adociastes ihtw hgescan in reptkstoos txaesilyu in tsnatpie in eht tsnrpee y"tu.sd

nioLgko ta the tusonieq ,aaing Im' neugsgsi the aifgu"te dna iditfnfgcliu plesinge dan gicaectnrnnt"o atenetsmt wsa uspsdeop to be a ulec for eenpssiod,r aiselelpcy nscie it sttraed afetr sih osert.k Aslo, no haylscip mraetilbsoian ssguget gfncunitoni si tntiac nad hstu aorulntcn tenoiserc uodlw be rrvdeepse llorn.mya Tihs is utjs siptud.

ls3076  appreciate this kind of effort to look up journal articles but honestly this is not really what nbme answers is for... we should be able to get the answer from process of elimination/basic science concepts and not from looking up studies as we obviously can't do this on the test +  



 +0 
submitted by cathartic_medstu(28),
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Onrcgia D:E lnarmo ,bodiil aceddeers lnurancot srecioent

cecyPiohngs ED: esaecredd lodi,bi loamnr cunnaolrt eoitrscen

oGt i.t




 +0 
submitted by ls3076(73),
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sI aseecdred trnlaucon sneoetrci ton eslobsip edu to eht nouyiginctr ebteewn esont of mmtspoys dan rsktoe 2( mso ruesvs ?)3 eAgre hatt eshte isneouqts era evry uegva nda tt.irfanrgus otN seru ehwer ot tge a odog rspga on hsti artai.mle




 +0 
submitted by cathartic_medstu(28),
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rlucNnoat npilee scumeteecn tamemreeusn lgayhrhal(op)p is a estt that aussreem esspunooant tlghnyi notsrceei ni leieretc dcioynufstn ylrrpa(imi prefordem ni a pesel aot).yarrobl tsI' ulfseu rfo fidneirienttafg etwneeb gacinor fmor cgpyeshocni eiectelr fnyoncsdui.t

Vtgnetei srcbeside a ylsoispb eepdressd ienattp t;&g= yecgcshonpi ectriele dfns.ucoytin eSnci it is otn an rgiocan ceuas of DE, tnnrlcuao oeinctsre loudw eb lnmoar. nigcOar ioesleogit fo ED encldui iengnoceru or avlar.scu

diLibo arpt ssecufon em erh.e idioLb smena xlsaue reside ro tpte.paie I was gintnhik cnies se'h igomcn in to get ED hedeck,c it stiadcnei hes' itpeetap rfo xes is oehugn atht ti adem mhi get it .chcke So dbiloi shloud eb marn.lo yAn hlpe?




 +0 
submitted by mattnatomy(43),
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sernwA = cedeDreas o;biidl nlarmo lautorcnn rceeinost

I lbiveee waht yhte rewe nygrti to ecdaitni in itsh iuqetnos swa lhoigysacPocl exSula nnDoityucsf aak( - mafcPrneoer x.)tinAye

nI hsit csea, ti ntwas' os uhmc eth orceenmapfr ttha oidrrew eth n,ma tbu eh may eb so uscoefd on sih hatlhe sssiue psot( oks)t,re htta he is ualbne ot efrromp leyet.uaqda eTrrho,efe shi laarntu boilid uolwd be erd.csdeea Heorwv,e ebesauc i'ts pyehgcnsico ;p&ma nto y,goispciolh he ulsdho itsll aevh mnorla ihttnmieg cseenirot.

b1ackcoffee  Wouldn't pshychological SD have normal libido and just performance anxiety? +