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NBME 20 Answers

nbme20/Block 1/Question#47 (29.5 difficulty score)
A 60-year-old woman with type 2 diabetes ...
Rupture of a papillary muscle🔍,📺

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submitted by hayayah(1100),
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heT wot tosm anpotmrit IM sconiaolmctip hatt rcuoc thwnii a 5-2 ayd naps ear aaippllyr scluem reprtuu dan lecniarirnertvut tpmues euurrt.

irylpaPla lcmsue ruerput leads ot vesere ltaimr orgt,aniutregi derah sa a otslysic umurrm ta hte eapx.

dulxy071  I disagree. any sort of rupture is usually the result of the action of macrophages (to eat away dead, necrotic tissue) which come in on day 3. This was merely a word game to get the time line right. They said "TWO DAYS LATER" (keeping in mind our time line starts 16 hours after the first symptoms appeared in this stem) which actually turns out to be day 3 +6  
leaf_house  Wouldn't necrosis of the interventricular septum create a VSD, which would also produce a loud, (holo)systolic apical murmur? I don't get how we're supposed to differentiate, here. +1  
mangotango  A VSD produces a holosytolic, harsh-sounding murmur loudest at the tricuspid area, not the mitral (apex) area -- FA, pg. 288, 289. +5  

submitted by queenofhearts(14),

This patient has some characteristics of myocardial infarction including a sudden onset of severe “crushing” substernal chest pain that radiates to the left arm, shortness of breath, and jugular venous distention (JVD). Complications of myocardial infarction include cardiac rupture which is seen in this patient. The effects vary with the site of rupture; from the patient’s mitral insufficiency {i.e. systolic murmur at the apex} we can see that this is a rupture at the papillary muscle.

Resource Kaplan Pathology Page 94-95