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NBME 24 Answers

nbme24/Block 1/Question#27 (39.9 difficulty score)
A 10-year-old girl with a lifelong history of ...
Palpable right ventricular liftπŸ”
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 +19 
submitted by lsmarshall(393),
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Pae"rrlanast aheev f)lt(i ocrusc nudgir rithg tcvrirealnu yryoepthhpr .e(.i e)egranntmle ro yerv eylarr reeesv eltf aritla t.anm"nreelge RV rotheyhyrpp cna be eesn so aelisy cbsuaee teh RV is at hte oitrnaer urefasc fo het s.ceth

In siht naettip obdlo romf AL to VL deeescrsa ni ,aoatrsnuit os ti is gingo s.mhoweree rmFo hte 2O sta. ew cna eucedd ereht si bolbpyar a VDS (aeeriscdn VR rusesper olwud sucea HRV dan rltaneraspa .)eaevh h,terrrumFo the eetvitgn is kilyle dsriibnegc rttoeglya fo tlfoal e(ucsda yb rpoaeotinrerus peaietcnmsld of teh iabriunfldun .etmpu)s nI teT lp,less RV uowltfo si oto srbtedouct nad tiaepnt esgt iynocsas and ;g&tLR gtnusihn usatSq nciseaer ,VSR deganrices gt&;RL hnunig,ts tgupnti emor dobol ouhrght paonmylur ircctiu nad rigleeivn niasoycs.

seagull  i'm pretty sure your a prof and not a student. +15  
nor16  nevertheless, we are greatful for explanation! +  
niboonsh  I remember seeing a question describe parasternal lift in the context of pulm htn. still got this wrong tho fml +  
anotherstudent  Did my question have a typo? It says O2 saturation in the right ventricle is 70, which is equal to the Right atrium and vena cava. It says the O2 saturation in the left ventricle is 82%, which is a decrease from the LA (95) but not equal to the RV, which is why I thought there wasn't a VSD, I assumed there was a weird shunt from the LV to some other part. Will O2 saturation not always equalize? +1  
pseudomonalisa  This is a right to left VSD due to the pulmonic stenosis present in Tetralogy of Fallot. O2 sat will be low (70) in the right ventricle, and from there it'll enter the left ventricle and mix with freshly oxygenated blood coming from the left atrium (95). Because of the mixing, the O2 sat of blood in the left ventricle will be somewhere in the middle of 70 and 95 (82 in this case). You're correct, though, that most other VSDs are left to right and you'd see greater O2 sat in the right ventricle in that case (not sure if it equalizes with the left ventricle though). +  



 +1 
submitted by humble_station(68),
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coNeit dpro fo 2O naitrotsua orfm AL (5)9% to LV 7%)0( pm&a; lauqe 2O nosruattia enbtewe VL ()70% m&pa; RV 7%0() -gt;&- VSD is tnrpese

oNietc teh rseuserp fo het VR /(0612) – Namolr RV errpsuse is /255 hiwch acintesid incserdae eesruspr ceesbau of het eecnsrdai uleomv of oblod ocngim rmof eht VL tgouhrh het VSD

aedrG 4 rrmuum is a alalepbp thlril otms ylilek deu ot RHV omrf hte deordleova work

thotcandy  classic eisenmenger syndrome +  



 +0 
submitted by drpatinoire(12),

I just want to mention that kids squatting is very much suggesting a TOF in USMLE..lol. And her pulmonary murmur suggests pulmonary stenosis, which further supports TOF.

peqmd  Not necessarily. Squatting just helps to increase preload => this will expand the left cardiac chambers and reduce R->L shift. It's a general principle to R->L shunt heart defects not specific to one disease +