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NBME 23 Answers

nbme23/Block 4/Question#24 (46.3 difficulty score)
A 60-year-old man comes to the physician ...
Erythropoietin🔍
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 +16 
submitted by thomasalterman(153),
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eianttP sha lmieyphocaty ,eavr sa eecveidnd yb tecroorhy,ssity ngcauoots,rlsyi adn eesdachah p;am& sd.neiszi EOP is acdsderee ued ot .ortseyctirsyho Dsearceed PAL lwudo daieitnc L,CM tno .PV

btl_nyc  I thought this was CML. What am I missing that would say CML over PV? +4  
btl_nyc  Nvm, RBCs go down in CML, but everything goes up in PV. +9  
arcanumm  Tricked me. I knew right away that it was PV, but I thought PV would crowd out normal cell creation (e.g. decrease platelets). So apparently crowding out normal cells is just a quality of AML/CML? +1  
drzed  More AML. Remember Sattar always stresses that all the myeloproliferative disorders are expansions of ALL lineages, ESPECIALLY "xx" (depends on which one, for CML it'll be granulocytes, for PV it'll be RBCs etc). They're called MYELOproliferative because all the myeloid linages go up, but one will be increased more than the rest. In this case, it is the RBCs. +3  



 +4 
submitted by guillo12(47),
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VP" si a litocnpaes ac)nl(ol oobld ridsdoer ithw mououtsnao nndedOi-peP(tEne) riedrohyt atririopoen.lf aesecBu of the eenesitxc fo a tavneegi kebfecda i,emasnchm teh coyishtosrrte ni PV lwotgsa-rdeenu EOP irnopdcout dna esusrtl ni wbole rnmloa rmuse EPO .lsevel In acn,tosrt na virEe-dOPn hyrortcetoissy rtszirceaceha snerdayco tcsehrioyt,sroy dna stih ionitodcn mya be tdaisaeosc hwit trheei ihhg ro amnorl rmseu OEP eles.lv"

wtr6.pe3o/xsoih(p1yn6ci5ctulic4eg:)w1ig80cls/a1.m-nloe9rta8d0t06lew-f/tS2//r

qball  For those that want to know what total red cell mass means in polycythemia and PV read the first paragraph in this article. The hemoglobin and hematocrit do NOT inform you of the total red cell mass. +  



 +2 
submitted by runnerman92(2),
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ecIreadns Leesvl of eidolMy clels ( crtosotyEhsi,ry heimtyatrcbmoo,h dna gis)lcyosotarun sulp issnzzDie dna edcahHea cnrseiae eht sipunicos rof myelioahyPct ve.ra

Low POE ni VP ude to igtNeaev kbafdece on OEP learese by nkidye.

dentist  This is where the timing of everything in the question trips me up. FA say PV mechanism is increase EPO (2019, p299) +  
paulkarr  Different types of Polycythemia have different effects on EPO levels. "Appropriate Absolute" and "Inappropriate Absolute" will both increase EPO levels (Inappropriate is caused by this EPO increase). Where as Polycythemia Vera has decreased EPO levels due to the negative feedback loop. FA2019 pg 425 hooks it up nicely. +5  



 +1 
submitted by abhishek021196(62),

Primary polycythemia = Disorder of Increased no of RBCs, usually due to acquired JAK2 mutation. May present as intense itching after shower (aquagenic pruritus). Rare but classic symptom is erythromelalgia (severe, burning pain and red-blue coloration) due to episodic blood clots in vessels of the extremities. There is DECREASED EPO (vs 2° polycythemia, which presents with endogenous or artificially raised EPO). Treatment: phlebotomy, hydroxyurea, ruxolitinib (JAK1/2 inhibitor).