NBME 22 Answers : Block 2 : #7 = A 66-year-old man comes to the physician ...

NBME 22 Answers ↦

nbme22/Block 2/Question#7 (58.6 difficulty score)
A 66-year-old man comes to the physician ...
Libido: decreased;
Nocturnal erections: normal🔍
tags:

+4 upvote downvote
submitted by paperbackwriter(71),

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 +1

+3 upvote downvote
submitted by iviax94(7),

unscramble the site ⋅ become a member ($36/month)

Tereh vhae been a ocpelu of eqsutoins bouat thsi cptio no eht rewne masex. ’eIv eneb nsaewnirg by etaiuqgn iobldi to stsoeertteon sllvee dan trnnuoalc crtseieon to talheh of luvtcsauaer toscaolr(sihesre ro t.on) sI htis otc?rrec

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. +17

_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. +

drzed @pg32 bro spoilers +2

+2 upvote downvote
submitted by elf16(2),

How is this different from the question on NBME 21 in which a 68-year old man also had psychogenic ED? But the answer was normal libido and nocturnal erections.

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 upvote downvote
submitted by cathartic_medstu(24),

unscramble the site ⋅ become a member ($36/month)

ngarOic :ED aonlmr d,bolii ecddaseer rtonanclu rnisetoce

ciocehPnygs DE: ersededac bilo,id arnoml oaclntrun rctsoneei

otG .it

+1 upvote downvote
submitted by adong(81),

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 upvote downvote
submitted by nwinkelmann(252),

unscramble the site ⋅ become a member ($36/month)

,So I gtthuho hits tesuoiqn saw pseur eguva nad not .a.e.trg tath ebign s,adi ahivgn ttgneo it worng and not lyrela gnhvia a odog nxotlpaiaen for eht wn,reas I idd a tlilte rahceser nda dofun hsit cet:rlia 071Rthd156h/upa1gp.:.1S1jol/odwt4wf0.//r/.13Tsawsi/no.ar.0.

ishT aws eth aimn losncucio:n h"Te sserltu fo het tenesrp dtusy, amied at eaisssngs the eftesfc of orekst on uslexa ionct,figunn verael a sinacintfgi edenlic in dl,iobi cltoai yfucr,qeen uxasel aarsuol, and tiistnfasaoc htwi alxues feli in boht esoktr patentis nda trhei us.osspe heT epentsr tlusres aols stenadtmeor atht dosreisrd fo uelsax ftnuiscon are ostm fnclnigityais scaoeatdis itwh ouairvs cyposihocals osa,rtfc hcsu as enstaipt’ elnarge etidatut toarwd ,iasxuetyl afer fo meictpoe,n nda tibyial to dsscius lxst,aueyi sa well as hwti hte dgreee fo etsstokrpo fctinuonla aytilb.siid ,Mreevoro saeulx dtnifoncusy was rdletae ot het necsepre dan gerede of snierdop,se atbeeids sml,teiul nda icloraacavsudr ict.imodnae ehT toyeilgo or olnociat fo het srkoet nad eht egdner or mratlia tatsus fo teh sttpinae ewre ont dasoiatsce wiht ecangsh in okoptsrest uayiexstl in tntiapse in eht tpesren s"dt.uy

kgoLoin ta the tonuqise aa,ing Im' gsgsinue eht giaeuft" dna iftluncidifg negilpse and ctencarontgni" eteatmnts saw uoeppsds to be a ulec rfo ,odpissnere scplleeiya ecnis ti erstdta ratef ish etsrk.o l,soA on lcihayps iriataeslobnm gsstueg ignfnioncut is naictt adn suth oanrtlncu tsinrecoe oduwl be dsereervp .ylranmol Thsi si sjut utp.ids

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 upvote downvote
submitted by ls3076(60),

unscramble the site ⋅ become a member ($36/month)

sI dseaeecdr annucrotl erecotisn nto osiebslp eud ot eht giyirnuncot wbetene osten fo ptsoymms and seokrt 2( smo eurvss ?3) reAge atth ehste qoesitnsu are ryve ugvae dna runiagfrstt. oNt urse werhe to tge a odog pagsr no ihts taae.rlim

+0 upvote downvote
submitted by cathartic_medstu(24),

unscramble the site ⋅ become a member ($36/month)

alNutrcon lnpeie nstcueceem remtaumense hpply)ghao(alr is a tset htta massereu npeousntoas lghynti snieeotcr in tlrieeec ydsionutcnf yrmaplri(i reerofpmd in a lepse .)ayroorblta 'tsI uesful fro ettfneidfgniari wetebne craoing rfmo chpnecyosgi tlcireee .yonunitcfds

Vneiettg brceessdi a obssilyp drsepsede piettna ;=> csciypogehn ecrtelie ysni.octdfnu necSi ti si tno an coiangr ucaes of ,DE onclartnu iecrtesno ldouw be oa.rmnl iOrncga eogslitoie of ED iduncle oegenrcniu ro laura.svc

iboLdi aptr csfsoneu em ere.h Ldoibi neasm aluesx rdisee or paiettep. I saw hntingik ciesn hes' ncomig in to teg ED hcced,ke ti taiecsdin h'es eatpetpi fro sex is hugneo atht it emda him tge it .chkec oS dboili shodlu eb l.namor nyA peh?l

+0 upvote downvote
submitted by mattnatomy(41),

unscramble the site ⋅ become a member ($36/month)

sAenrw = Dadsrceee dbilio; namorl uatnnorlc icnstoere

I elebiev wtha yhet wree girtny to ediincat in iths tusnoqie was oscoglilcPayh aSeulx touiyDnnfcs ak(a - freoPamncer ixy)eAnt.

In stih s,aec ti s'ntaw so uhcm het noceefrmrap ahtt iorerwd eth anm, ubt eh amy eb so cusodfe on his ahhlte sessui stp(o rsot)e,k thta eh si naelbu to proemrf qlytau.aeed oehf,Trree shi lauratn odiibl owuld be ee.srddeca ev,rowHe ucesbea it's cienhpyogsc pma;& otn choi,psoigyl he ulohsd sillt veah lmnaor niieghmtt nr.siteoce

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