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NBME 21 Answers

nbme21/Block 3/Question#11 (72.1 difficulty score)
A 50-year-old man is found dead in bed at ...
Arrhythmia🔍,📺
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 +14 
submitted by cantaloupe5(81),
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yHgotsiol whosed cgtiaaeulvo escosirn e(vreserpd tucracreteih of raoyadimlc )fierbs whit euiotlhnrp toinlifaitnr hhicw deinth ttha teh IM wsa winith 42 u.rohs sotM eykill caseu of htdae htiiwn sritf 24 husor fo IM si tyma.hrahir rlcyioaMda pureutr uldow lsoa eb lisveib no gorss eapcrpnaae fo het r,eath hhwci htey dcbeirsde in het se.mt

bighead478  in FA it shows softening of the myocardium to happen at 3-14 days. Do you think this was overly misleading people (like me) into choosing myocardial rupture? I understand the histo features are consistent with < 24 hours, but the stem should also match this in every detail +14  
sbryant6  Myocardial rupture would not happen until 3-14 days. Since this shows signs of <24 hrs, the answer is arrythmia. +3  
hello  @bighead478 You have to look at the whole picture. Histo shows preserved architecture, which indicates coagulative necrosis -- coagulative necrosis is a histo finding only in the first 24h. The most common causes of MI-related sudden death are: arrythmia > cardiogenic shock (heart pump problem) > rupture. +  
jcmed  I chose the rupture as well due to the timeline. Somebody gave me this advice the other day, NBME classically will give you an entire vignette leading you somewhere, and the what it asks will be something completely different; or in this case will give you a photo of something and will ask about the photo. They do what they want. +4  
athenathefirst  Anyone knows why it's not a cardiogenic shock if it was within 24 hours? +2  
zevvyt  It says "Mottling" which happens in the first day. If it was 3-14 days it would be yellow (p 302 2019). He can be having angina for 3 weeks leading up to an MI. +1  
amy  The stem of the question said "softening" which indicates 3-14 days (rupture ), and "mottling" which indicate 24h (arrthymia). It seems from the picture in FA2020 page 305, coagulative necrosis would be there during both phases. The cells in the picture are so small that it is hard to tell if it is purely neutrophil or if there are any macrophages. Still seems like a very confusing stem to me. +  



 +11 
submitted by hungrybox(1110),
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/u/lctna5oauep adh a ergat aie.nxoptlan

eseH'r na egima fo eth nfftiered agetss nwolligof iylrdmocaa atfr.niocin Ntoe the nocaoritc"tn bsna"d rae tahw dfeien utglaoeiacv nos.iscer




 +2 
submitted by volcanobuns(2),
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IM dsunde ehdat g&;-t rrhayhm.ait The rredo of scsneonomm is artymhhria &;tg anericodgci shokc gt;& ruer.utp




 +2 
submitted by zpatel(26),
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/2pdVht..edLt:/aCm7h/aupmteh/Ttbeh1lutsC.VM.Hw

ckceh sith uot

smpate  Nice find, thanks! +  



 +0 
submitted by frimmy_11(0),
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Mglnttoi nad fotnsgien of ertaoinr wall no pytuaos gtssuegs ti asw otn redol thna 24 .rsh aDthe fomr laatf tryarmhiah kiel fibV- msto monclomy uscocr whinit neo day fo het I.M Tath ,isda neoc rsca hsa omrefd ni mcoalyiard ustsie ,it ,oto anc eucas iyrhtm.haar

bighead478  in FA it shows softening of the myocardium to happen at 3-14 days. Do you think this was overly misleading people (like me) into choosing myocardial rupture? I understand the histo features are consistent with < 24 hours, but the stem should also match this in every detail +  
athenathefirst  Anyone knows why it's. not cardiogenic shock since it happened within <24 hours? +  
lovebug  @athenathefirst I also had same Question. maybe Question asks "Most likely mechanism of death" > most common cause of death in 24hr is arrythmia. cardiogenic shock is also possible. but it's not the most common cause of death within 24hr. +  



 +0 
submitted by an_improved_me(64),

Question: even if this pt did have myocardial rupture... is that even a cause of death? I feel like like the mechanism of death in myocardial rupture is cardiogenic shock; blow a hole in your heart, and suddenly it aint pumping so well. Just asking for future reference.