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NBME 22 Answers

nbme22/Block 4/Question#43 (29.6 difficulty score)
A 44-year-old man comes to the physician ...
Tricuspid insufficiency🔍,📺

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submitted by pppro(23),
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IV rudg aebus + R etahr fiaelur sympomst gescteodn( vei:r)l hnikt iprsctdiu ycfuciniseifn

fukprometric  why couldn't it be something cirrhosis related given his IVDU? I was thinking that the increased systolic pressure was a sign of portal HTN from cirrhosis so he'd also have a portosystemic shunt, but that was wrong +1  
schep  I picked portosystemic shunt, too. Looking at the question now, I should have focused on the fact that he is IV drug user, has a fever and has signs of right heart failure (back up of blood into the liver) which makes me think endocarditis +  
jaramaiha  Portal HTN wouldn't give him a fever, but those septic emboli would. TBH to go 10+ years as IVDU w/ no heart conditions, he seems to have played his luck, but luck has run out :( +  

submitted by adong(102),
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tgo seocfnud yb eth oltsyisc tplosiaun fo hte rliev btu lycasilba gtugnterari bdool mrof VR llwi go inot AR g&;t VIC g&;t hipaect vnesi

submitted by medbound57(7),

according to B&B, a "pulsatile liver" is a classic finding in severe right HF because the tricuspid regurgitation is transmitted to the abdomen.

ivypoison  Hepatic pulsation is wave from aorta in systolic. Normally (no tricuspid insufficiency), no congestion,no pulsation. In tricuspid insufficiency, ventricular extrasystole (blood from ventricle regurgitate back to vena cava and hepatic vein rather than to lung) + wave from aorta -> hepatic pulsation. Also weak S2 +  

submitted by confidenceinterval(3),

I was between tricuspid problems or cirrhosis from hep C. I think if all they give you is a bounding liver go for the valvular problem because cirrhosis would have more symptoms like increased estrogen. I also think the problem being so acute also points to a cardiac origin. Reading the question again, portosystemic shunt isn't so much a diagnosis as a sequelae. I could imagine tricuspid insufficiency eventually causing shunt, but that's not really the underlying diagnosis.