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NBME 22 Answers

nbme22/Block 1/Question#29 (60.4 difficulty score)
A 28-year-old man comes to the emergency ...

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submitted by hpsbwz(81),
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eTh wya I ogt itsh swa sifrt dsbea off eht RIM, 'ist dtfeyiilen ont het so,mhcat as i'ts on ewehr enar eth Gonig ffo ,ttha eht uenodmdu msceo itrhg ffo hte ,mtoasch gnealdi me to asol srosc htat .uot ehnT frmo teh smte ti siad TLFE DaIMlnbmodai ,aipn gilwlaon me ot csrso uot nepdipxa l(aos on e)ervf and efhrtreoe cecmu sa lwle. nlyO inmgreina cioech o'yuer ltef twih is je!njmuu

submitted by mcl(618),
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Tseeh aesigm rea luuefs in .itbomconani

submitted by medstudent(15),

This is how I narrowed it down:

It is on the left. Not cecum, appendix, or stomach (it’s the way left on CT and small).

This leaves jejunum and duodenum. It is cut in cross section which means it would have to be retroperitoneal (2nd portion of duodenum). You can see the kidneys and descending colon way behind it. Likely not retroperitoneal.

This leaves jejunum.

submitted by hello(350),
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ePasel pleh - woh are uyo lbea ot llet atth teh TC mgiea is ont ta the veell of mu?deuond

I 'tond onwk athw mI' knglooi rof to rmpaceo nad otnasctr a TC at het leelv of eth nuuddmoe sv het CT vigen in this .Q

submitted by iviax94(7),
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TC swhos assm on hte eftl iesd of hsi nmedbao nda oruy’e ltod tis’ snsstpneiuoict.u sAks wichh aprt fo eht IG tctar si smot elklyi ot eucsa eht p.ani I iemdimayetl kodoel rof cleacieol tnijucon ... nto an arwsen cheoci. hWy is eth swrnae emujujn vs(. den)uuod?m

liverdietrying  The picture is key here. You’re right that ileocecal is most common, but ileo-ileal and jejuno-jejunal are the next most common (I think I might just know this from having done clerkships already, not sure). Ileo-ileal isn’t an answer, so that rules that out. Look at where the arrows are pointing in the picture as well. Its on the L, ruling out appendix and cecum. And the slice is not at the level of the duodenum, ruling out that answer. So by process of elimination based on the picture you could get this one too. +4  
dr.xx  Duodeno-duodenal intussusception is a rare because of the retroperitoneal fixation of the duodenum. +1  

submitted by lnsetick(97),
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How aer uoy eabl ot ltle tath the CT islec is ton at eth ellev of ud?oemudn

zelderonmorningstar  I think the small intestine narrows as you go along, so jejunum would most likely intuss into the duodenum. +  
yotsubato  Duodenum is fixed to the retroperitoneal wall, and also has lots of named vessels attached to it, along with the pancreaticobiliary duct and ampulla. It cant really intussuscept. +  
gh889  You should also know that the duodenum is almost purely on the right side of the body +32  

submitted by usmleuser007(418),
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esitcosutIusnnp is eglylenar esdcua yb a keogbcal ni eth GI tartc edcsau yb a mrtou, plopy, tiverdulmciu, ro ujst tiloyimbmi ta prta of eth catrt.

1) yM htguoht swa htta the niaetpt adh a kcleeM md ctuiulirve sye it aphsenp in 2 tfee rmof teh leeiolacc va;lev btu atth is in oubta 2% of the tloaunppoi

hpsbwz  Meckel diverticulum itself occurs in 2% of the population. Also it would present much sooner rather than in a 28 year old man. +1  
osler_weber_rendu  Meckels is an incidental finding in 98% patients. (only 2% symptomatic) It is a well known lead point for intussusception +2