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NBME 18 Answers

nbme18/Block 4/Question#3 (19.1 difficulty score)
68 yo man, 3 days of increasingly severe deep ...
Aortic aneurysmπŸ”

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submitted by mousie(210),
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mcdumbass  Adding on, hoarseness + difficulty swallowing means something is pushing on the recurrent laryngeal. Murmur in the second right intercostal space = AR, AS, or Pulm regurg --> AR associated with thoracic aortic aneurysm, or at minimum, you can infer it's a cardiac etiology +4  
chadgas  The dyspnea, dysphagia, stridor, and cough are pretty indicative of a mediastinal mass. So expansion of the aorta can cause compression of the esophagus, trachea, recurrent laryngeal nerve, etc. depending on the severity of it. +  

submitted by masn8cc(2),

Can someone explain how they r/o aortic stenosis? because that could enlarge the LA and give the same sx of hoarseness etc. And the murmur also fits with AS

bmalamet  You would not see a "viable pulsation above the manubrium, which you should not confuse with a "brisk carotid upstroke" associated with aortic stenosis. +2  
nbmeanswersownersucks  "brisk carotid upstroke" is the description of a normal carotid pulse. Aortic stenosis has a slowly rising/late peaking upstroke since the stenosis impedes flow out of the LV. +4  
overa  AS affects the LV first. it isn't until later in the disease progression that there will be a significant enough enlargement of the LA to cause impingement of the LA. By the time the problem was that bad there would also be pulmonary findings of backed-up pressure (in my not so expert opinion). +  
305charlie94  Can anyone explain why the trachea is deviated in an aortic aneurysm? Made me think of a pneumothorax here +1  
baja_blast  ^It's basically mass effect. Aortic aneurism takes up space in the thorax, displacing the trachea to the right. Take a look at this CXR: +3