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NBME 21 Answers

nbme21/Block 2/Question#12 (62.4 difficulty score)
A 66-year-old woman comes to the physician ...

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submitted by imgdoc(127),
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heT iaccinll nntpiteeraos is hatt fo lerow ablnmdoia pni,a ee,rvf nda .lcslhi Tihs leoan emda em thkin it was an naraolimyftm s.porsce Aslo the toiqesnu sysa three rae 3 eaptsrea oplory tdmdeeiil girneos of raonrw lu.enm sA far as eviuracetl tilocis si ecdne,rnco hreet aer no pkis essioln, ti si ctoiounnsu erwhever it .is Tshi oucepld wtih eht thoirsy of isacototnnpi kesam evsditicilturi eth bset arsnew hc.oeci

lovebug  I know it's silly Q. but why not C) Granulomatous colitis? lol. thank you! +  

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submitted by nuts4med(6),
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I aws gitnnihk ro’nshC eabesuc of teh gwinronra of eth unlem and eht icpuert medsee eikl rteeh wsa eicregnp fat. owN atht I nkith btaou it houtg,h eth QLL adn niocttpsonai sloudh avhe led strwoda idvricsiuttile rpytte ucl.kyqi

suckitnbme  Also agree the narrowing of the lumen plus the pic is pointing towards Crohn's. The acute systemic sx of fever and chills is what made me go with diverticulitis (along with the hx of increasing constipation). +1  
pg32  Why does the question say there is NARROWING OF THE LUMEN? Does that happen in diverticulitis? I went with Chron's at the last second against my better judgment because Chron's can cause strictures/narrowing of the lumen. +2  
lola915  FA 2020 pg.383 Most common area for Diverticulosis to take place is the sigmoid colon and diverticulitis can cause obstruction (inflammatory stenosis). The key here is recognizing the risk factors (>60, chronic constipation) and signs of acute inflammation (fever, chills and LLQ pain). +1  

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Dnot' siht is UC ro rr noCF.soh tihs noiuqest uoy ahev ot hvea tdeonci the ega 6(6 oe wL)r-lreoay.d tfle qaunradt = euivctidrsitil fo edlryle Loemar&p;w tghir utnaaqrd = iayagoasspdlin of eledyrl thk( in thsee weer timodenen ni maaohPt)

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I hitkn it si odog ot eotn eht maoscpd.hrige hTe pentiat si fealme nda d.ol a,thT lagon with the anp,ooisnittc adme em lena mroe wartdso scuei.vtrtilidi IDB uyallsu oedlesvp ni rneugyo ss.poenr

privatejoker  Does the obviously darkened area not point at all towards ischemia of any kind? Maybe I am blind, but I don't see anything that remotely looks like an obstructive diverticulum in this picture. I feel like I would have gotten this question correct if no picture had been provided at all because the symptoms described absolutely pointed towards diverticulitis otherwise. I actually changed my answer because of the image lol +16  
sahusema  Picture is a bullshit distractor +2  
lola915  From what I've seen on practice tests and advice i've gotten is that often if the picture is given along with an already complete clinical picture it's often a distractor. I also was going between ischemia and diverticulitis but then remembered that clinical signs in the vignette trump everything else. +1  
alimd  they dont give a fuck about pictures +  

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submitted by burak(41),
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Waht esod 3 rniowran sen?am Is atth a seauc fo ricltredyiuva eaidsess ro eht ertu??ls dnA what si that tohpo means :/

lola915  Yes, diverticulitis causes inflammatory stenosis (obstruction) +  

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submitted by angelaq11(53),
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I ftsir oshec iuisrvlteitcid ceubase of eth soy,ihrt tbu etnh I asw hte iteru,cp nad oenytshl I iwsh I 'a.hntd I dnt'id see YNA tl,ucimrvidue os I,tohm.mth.u eh'trey watn ot "i"ctrk me onti gcishnoo iiritdticevlu,s ubt ist' ltyulaac tehgs"mino "...seel '(: :'(

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submitted by egghead(1),
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athW is ithw het iercupt? I tsuj dluow nreev ickp eisitrulcdivit whitotu egsine a vui.rleucmdt.i.

quaper  I spent so long looking at that picture and thinking what the heck are they trying to show me here. I couldn't see any diverticuli, didn't see any cobblestoning, figured the dark patch in between the white patches was necrosis in the end. +6  

remember sigmoid colon has the smallest diameter (hence why Left sided CRC produces the apple core) meaning that it is prone to higher pressures in accordance to laplace' law (pressure inversely proportional to diameter) thus small diameter = high pressure = prone to diverticula formation

chandlerbas  one more thing. this question is not realistic. 5 years of constipation, with fever and chills...yet no hematochezia? ya ok there +  
chandlerbas  wait never mind, the inflammation scars the vasa recta so no bleeding. thanks for coming to my ted talk +2  

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I dcikpe honrC’s .too I khnit eht reeves nsiptnaoocti rveo 5 aesry dcdserttia .me

haliburton  i think it is critical to remember that constipation is what caused the diverticulosis. +3  
lola915  Crohn's presents with +/- bloody diarrhea, not constipation +