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NBME 21 Answers

nbme21/Block 3/Question#12 (46.1 difficulty score)
A 55-year-old man with hypertension comes to ...
Left renal artery atherosclerosis🔍,📺
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 +5 
submitted by pg32(174),
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Erw/UldBoNM ovle to stte nlare rtyaer osnsites ni eth tngtsei fo eineyhervtps /gecryu.eycrnmngee sJtu eesubca this has nbee dnoe os nmya ,tmise oyu nac alablcsyi egt eht rgith enswar rmof eth irfts fahl of het t.oqueins Pt iwht end gaorn issseu ,dah(eehac oicnnfu)so dan rellya hhgi BP I( nwok it ins't 100/182, ubt ti is yrleal g.i)hh oS iths ugy yalbiclas has nehterseipyv .yecgrnmee Im' ardeyal hikgnint ist' relna ryraet ssosntei. Ntxe ?eesenctn A urbit ervo the ftle aodmnb.e inoB.g eRaln eaytrr sotesin,s smto onetf sdecau yb irrecstoasehosl ni orlde mne sa( dpaermco to orbusucrmlifa sydsailap in enurogy )mneo.w

lovebug  He is heavy smoker but, No weight loss, No cachexia -> so can be R/O Left renal cell carcinoma. is it right? +  
lovebug  Renovascular ds. FA2019, pg 592. +  
misrao  and no hematuria so r/o RCC +  



 +2 
submitted by necantoramericanus(2),
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mI otn raleyl esru ubt I hknti teh ntpoi si atht whit teh iptolprca uedoiicldarn cnas ehter si a edaly in ucfotnin of hte y.dnkie tahW yteh ndatew us to emebemrr hree is tath ehnw oyu veig a " A ilr"p to a tpeinat hitw ealnR ryatre trshloricsseeoa eht nelar nufcntoi woesrns buaseec heetr si nnrtsioiotcc fo hte ntreeeff oeeaitlrr

AF 0218 - 765

kevin  efferent dilates with an ACE-I due to loss of angiotensin mediated vasoconstriction +  
skonys  This is an aside but they love testing Renal Artery Stenosis in the context of ACE Inhibitors because it's a good physiology tie-in. First, it helps to know that Angiotensin II's entire role in the kidney/the reason it evolved, is to maintain GFR in the setting of low kidney perfusion (hypovolemic shock). It preferentially vasoconstricts the eff arteriole, increasing the pressure just anterior to the occlusion, thus forcing filtrate into bowmans capsule despite there being less blood volume running through the artery. In Bilateral Renal Artery Stenosis, maintenance of the GFR is completely reliant on AngII vasoconstriction of the efferent arteriole. If you give someone an ACE inhibitor, you decrease AngII and vasodilate the efferent arteriole. The force maintaining the GFR is gone, precipitating pre-renal azotemia. That's why people with suspected Renal AS need to have their CK monitored closely because it will increase after administrating and ACE Inhibitor. +  



 +2 
submitted by usmleuser007(418),
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usJt laezerid ttha lanre llec aancmocri tsi'n the ctcerro awsnre /bc ti indvaed teh usnevo iirtucolcan and tno the .lerariat BP may ton be ectdfeaf as cm.hu if CCR ewre hte nsarew enht neth trhee uwlod vhae ebne aedem nteesrp ard/no lrane HT.N

sympathetikey  Also, just thinking out loud, in the case of RCC, it's the kidney tissue that's dysplastic & moving, so technically the renal artery itself isn't dysplastic, right? +  
paperbackwriter  @usmleuser007 very good point regarding the venous vs arterial circulation that I neglected to consider! +  



 +0 
submitted by rainlad(25),
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Hwo od we nxliape eth rtibu ni hist a?ces oAls ywh 'nist it flet yarter rmnaes?yu That semes liek it olwud eterbt elxnipa eht buitr

gdupgrant  The bruit is basically just turbulent flow, which is most commonly caused by artery narrowing. I was just reading https://emedicine.medscape.com/article/463015-clinical on renal artery aneurysm and it looks like most of the hypertension is actually related to a pre aneurysm stenosis, so i think stenosis is the "better" answer, esp. since the pt has like every risk factor for stenosis. To be honest I had not ever really thought about RAA for this case because bruit over RA has been drilled into my head as renal artery stenosis, but i apprecaite seeing how this is a super reasonable answer - just the stenosis is "more likely" +1  



 +0 
submitted by usmleuser007(418),
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orF :CRC sA( epr URLW)DO

yScremimt blrelatia ewlro imrttxyee intgpit demae dna rouutsto mnilaodba ensiv rae cnnrncioge orf iiraofn ren neva acva (V)CI nourt,isctob ,chiwh ni het itetsgn of a lfsd-edite fankl smas, e gssanulgsrte ecll CCaRco armcn)(i ihwt nteosniex toin the . CIV RCC cncusaot rof 0&%tg;9 fo all csmaenngiali rngaisi in hte kiydne nda si higyhl eoiassacdt htiw og s.kmni antsPt ei hiwt CCR syciasllcal vhea a tarid fo anfkl pi,na eblpalap ,mssa dna mthieraa,u hoghlatu nmya rmenai oiatyaptsmmc nuitl eth eiadses si eCRdc Cda.nva is a yhhgil slaraucv utrom sta naeidhvt eht eraln v ninie pu to %52 fo .a cses VCI onttbcriuso anc rcouc due to nilamnaltiru itnoexsne adn sborutmh rmtonf,aio arrthe tnah smas tefcfe frmo teh tourm .fseitl 

ehT tosoictrnub acn ucroc utcylea or ygaaurldl orev e i.mt In rcionch e,ssca allolcetar sonveu coainutcirl mya deoelpv aedsb no hte stie fo het orn.oscib tut inntrPeom mnobiadal lwoactl allarle s,vien sa in stih t,teainp stueggs nbitsoctuor of eht ppure eegmsnt of the C.IV

nor16  high blood pressure, i.e. Hypertension, risk factors for atheroscl., bruit !!! over left abdomen, secondary art. Hypertension. they always want the renal artery stenosis (like vWF in coag. disorders...) +  



 +0 
submitted by jackie_chan(28),

I approached this question because man with rather extreme HTN and abdominal bruit is quite often renal stenosis

ALso captopril renal radionuclide scan's function is literally to assess renal stenosis (looked it up, but i did not know that when i answered)