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NBME 20 Answers

nbme20/Block 4/Question#46 (77.3 difficulty score)
A 28-year-old woman at 32 weeks' gestation ...
Obstructive uropathy🔍,📺

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submitted by xxabi(267),
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Aols fro htsoe of oyu ohw era yttlola lseseclu lkei e,m ruiyanr tratc tsrnoticbou = vrotutebcsi htro.upay

skonys  I see 74.5 Difficulty score and think "word, I don't need to get this one correct" +3  

submitted by banieb(22),
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unDrgi het satl aflh fo ncerngapy idtilaon fo teh uppre ynaiurr rcatt nca rucoc eud ot omrceonpiss of eth tuerrse by eth rogwngi rutstsu/eefu nda hte ilane s.niemtilra The mropsneciso fo heets si not nowiallg ildfu spgesaa oint teh reddlba iansucg nurei buipuld in eth idk,eyn tsih salde to naidtoli fo hte ydiekn hatt sedn up icaunsg oampistymct .enhrispdsoyohr tihs nac end up in onicientf nda mosmtsyp schu sa the oens reetpsn ni isth tneipat iekl ckba napi nad AVC rnteensse.d eth iynrgc is ayimnl due to eht aipn dcuesa by teh nrbtsioocu.t dna stuj sa ghsienotm rta:ex elodub alipigt cthtarsee is a fsae adn eisplm ywa fo raetntig tacoytsmmip rhrinseodhysop fo pngcaenr.y

banieb  Ureteral obstruction by the pregnant uterus +1  

submitted by neonem(578),
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cbvtistuOre ayupohrt aussce a rtsonlape atiaomze &-;g-t wnhe lp,goornde arbtulu daeamg un.eess ihsT esald ot an atecu tulabur eirsncso, cdctizearerha yb oienrctc gpsul in eth rultaub smeyts as eens ni het aemig

meningitis  Does anyone know the relevance of the stem saying: "during this time she also has been crying frequently"? +49  
usmleuser007  Think the postrenal azotemia is d/t her pregnancy. With the increasing in size fetus, the pelvic cavity is being compressed and thus there is pressure on the ureters. This leading to the presentation. As per above --- the crying maybe just d/t her pain and emotional stress caused by worrying about possible complications regarding her fetus. +4  
maxillarythirdmolar  My gut tells me it must be some sort of transient change in placental size with hormonal changes. It's reminiscent of what you might expect for breast changes during the menstrual cycle, imo +  
j44n  or maybe the fetus is literally crushing her ureters into the wall of her pelvis and shes got an infected kidney +3  

submitted by waterloo(89),

I feel like part of this is them seeing if you can recognize those are tubules.

  • So if you say ok these are tubules, chorioamnionitis, endometritis, and PID are probably not right.

  • Glomerulonephritis in my experience so far, they should probably show a glomeruli, not tubules.

Between hematgoneous spread and obstructive uropathy, I feel like I don't have enough info - but sometimes a 50/50 guess is better than playing Battleship.

submitted by ye2019(3),
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siPalhcy emxas hwedso tesnsenred of oncceoprihst la,nseg whhic rea teh apelcs ewerh the pdahmragi )chnep-(ri smtee teh risb o-.cto)(s oNt het vbrottlsaeeoCr nealg nentdersse tath we hktni to ihnt nlaer eas.isedI got dsoucefn hiwt htsi .tnopi

adong  honestly think this was a typo. hot trash +2  
neovanilla  Assuming it was not a typo, how would the costophrenic angles be tender in this condition? ...From crying...? +1  

submitted by sympathetikey(1440),
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/nilDttaseonoitndii fo erlna vslepi adn scaelyc A . syuallU sdeauc by rrynaiu atcrt bnoicurtost r eln(age, ontse,s ervese BPH, oalicgtenn o,bntuisstcro erilccav cran,ce juyrin ot te,urer ryaencgnp eptyaplanr;) eothr nei cdsucesalu protrltenearioe rss,foiib ereutsrcoevlai liotDnai corcsu paoirmlx ot esti of Su eplotyog.rahm iecrnnitea oecmebs eavldete if tcoubtnisor si rlaeatilb ro if epntati hsa an ttyte ridouoblrassc .ikeydn Leasd to ipcssenomro dan bielsspo yothrpa fo elnra certox nad .lumleda

submitted by imgdoc(143),

This question was a little tricky, but the way I went about it was process of elimination. You don't see costophrenic angle tenderness in A,B, C, or D.

She has fever and back pain, definitely don't see that in PID, which presents with cervical motion tenderness, and purulent discharge. Micrograph also isn't showing cervical histology.

As an added bonus: urinary stones cause excruciating pain when you're trying to pass it through your ureters, basically dragging alongside. Hence the patient crying.

You didn't need the micrograph, other than to see all those neutrophils, but we've all seen glomerulonephritis histology slides, and it doesn't even look close.

submitted by redvelvet(52),
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hesopcrtoicn glaen nesrnedets dan fvrWee BC actss in suteblu on thta ohpot orf plaxmeelA l of emht si niaelgd su ot lhsnityopepr.ei dnA even omrin systtcii anc cusae pielhptieosnry in pncgeanry due to trsuotbceiv uto.paryh

diegolc26  I thought it could be D or E at first. But the picture is really clear. There is inflammation within the tubules, not in the interstitium, that points more for Obstructive Uropathy which is also painful, can cause fever, and a risk factor could be compression due to elarged uterus. +  

submitted by euchromatin69(12),
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recangnpy is a srki crtofa rof cetua t rpieFpAlyhnosie 0921 pg 958

submitted by laminin(16),
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losa eabmy cldou od scrospe fo .enmoteihiti.ln.a pnsriecoh'oct ngeal 'srdetsneen lsuce us in ot ti gineb a anrle emprb,ol dna het ylno nrela sarnew eihcoc is tibruseovct yrapthou

spdrwmn  glomerulonephritis was an answer choice +1