THE USMLE TIMES - #79
Highlights for the week of June 10, 2024
Welcome to issue #79 of The USMLE Times… We’ve now posted a USMLE-specific newsletter seventy-nine weeks in a row! Welcome to all new members of the community 👋
Here’s what’s on tap for issue #79 of the USMLE Times:
Question of the Week (Musculoskeletal)
This week’s video training (First Aid Dos & Don’ts)
Tweet thread of the week
Links to recent training
Mystery diagnosis of the week (NEW!)
Question deep-dive & breakdown
Let’s dive in!
A 29-year-old female presents with a 6-month history of widespread pain and fatigue. She reports tenderness to palpation at multiple sites, including the neck, shoulders, back, hips, and knees. She also reports morning stiffness and chronic fatigue. Additionally, she experiences poor sleep and cognitive disturbances. Her past medical history is significant for mild anxiety. Her vital signs are within normal limits. An imaging study shows no significant abnormalities. Laboratory tests are unremarkable. The most appropriate medication for this patient's condition works via which of the following mechanisms?
A) Inhibition of serotonin and norepinephrine reuptake
B) Inhibition of dopamine reuptake
C) Opioid receptor agonism
D) Selective serotonin reuptake inhibition
E) NMDA receptor antagonism
The answer & question breakdown is at the bottom of the post.
📺 USMLE TRAINING 👇
💬 TWITTER THREAD OF THE WEEK
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🔗 LINKS TO RECENT POSTS
Suffering From Premature P.O.E.? - READ HERE
The USMLE Success Limiting Skillset - READ HERE
The Hidden Danger of Mixed Questions - READ HERE
USMLE Times Issue #78 - CLICK HERE
USMLE Times Issue #77 - CLICK HERE
USMLE Times Issue #76 - CLICK HERE
MYSTERY DIAGNOSIS OF THE WEEK
Use the following signs and symptoms to diagnose this week’s rare condition.
Clue #1. Associated with BRAF gene mutations
Clue #2. Lower extremity long bone pain
Clue #3. Exophthalmos
Clue #4. Heart failure
Clue #5. Various neurological symptoms
Clue #6. Diabetes insipidus
Bonus Hint: This condition is associated with macrophages.
The answer will be provided in next week’s issue.
* If you think you know the answer (no cheating), reply to this email with your answer. Whoever gets it right will get a shoutout in next week’s USMLE Times *
ANSWER + QUESTION BREAKDOWN
The Mental Model for this week’s question:
Step 1. Identify the goal of the question (ID the correct MOA).
Step 2. Diagnose the condition and ask yourself, “What’s the drug of choice?”
Step 3. Ask yourself how your identified drug of choice works.
GENERAL ANALYSIS
The vignette describes a young female with a six-month history of widespread pain, fatigue, multiple areas of tenderness, chronic fatigue, poor sleep, and cognitive disturbances. The given signs and symptoms suggest a musculoskeletal condition. Normal imaging further supports the most likely diagnosis. Since the question asks for the mechanism of action of the most appropriate medication, our job is to figure out what’s going on and then identify the most suitable class of drugs that would benefit the patient.
ANSWER CHOICES:
ANSWER CHOICE A: INHIBITION OF SEROTONIN AND NOREPINEPHRINE REUPTAKE
Medications inhibiting the reuptake of serotonin and norepinephrine, such as duloxetine and milnacipran, are commonly used to manage this condition. Increasing serotonin and norepinephrine can help decrease the pain while improving sleep and mood.
ANSWER CHOICE B: INHIBITION OF DOPAMINE REUPTAKE
Medications that inhibit dopamine reuptake, such as bupropion, are primarily used to treat depression and smoking cessation. They are not typically used for the present condition and do not adequately address the widespread pain and fatigue.
ANSWER CHOICE C: OPIOID RECEPTOR AGONISM
Opioid receptor agonists, such as morphine and oxycodone, are potent pain relievers but not recommended for the treatment of this patient’s condition. They pose a significant risk of dependence and are not an ideal option for the long-term pain management this patient requires.
ANSWER CHOICE D: SELECTIVE SEROTONIN REUPTAKE INHIBITION
SSRIs are primarily used to treat depression and anxiety. While they can help with mood symptoms, they won’t be as effective as SNRIs in treating the pain and fatigue present in this patient’s condition.
ANSWER CHOICE E: NMDA RECEPTOR ANTAGONISM
NMDA receptor antagonists, such as ketamine, are used for their anesthetic and analgesic properties. However, they are not typically used to manage this patient’s condition due to their side effects and the availability of more effective treatments.
THE VERDICT: Let’s fill in the Mental Model missing pieces…
The Mental Model for this question:
Step 1. Identify the goal of the question (ID the correct MOA).
This question aims to identify the mechanism of action associated with the most appropriate class of medication for the patient’s condition.
Step 2. Diagnose the condition and ask yourself, “What’s the drug of choice?”
The signs and symptoms given in the vignette strongly suggest a diagnosis of fibromyalgia. The negative imaging further supports this diagnosis. The drug of choice for fibromyalgia is an SNRI.
Step 3. Ask yourself how your identified drug of choice works.
SNRIs work by inhibiting the reuptake of serotonin and norepinephrine.
FIND YOUR ANSWER:
Option A, “Inhibition of serotonin and norepinephrine reuptake,” matches exactly with the drug of choice we’ve derived based on our diagnosis. Therefore, we should select this option.
FINAL VERDICT: The most appropriate medication for this patient's condition works by inhibiting serotonin and norepinephrine reuptake (Answer A). SNRIs, such as duloxetine and milnacipran, are FDA-approved for the treatment of fibromyalgia. By increasing the levels of serotonin and norepinephrine, patients should experience decreased pain, improved cognition, better sleep quality, and reduced fatigue.
Key Points:
Fibromyalgia: Current guidelines for diagnosing fibromyalgia include at least three consecutive months of widespread pain that isn’t better explained by another musculoskeletal condition.
Management: In addition to lifestyle modification, SNRIs are effective in managing the symptoms of fibromyalgia.
FINAL ANSWER: A: INHIBITION OF SEROTONIN AND NOREPINEPHRINE REUPTAKE
That’s it for issue #79 of The USMLE Times!
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