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NBME 24 Answers

nbme24/Block 4/Question#6 (58.5 difficulty score)
A 68-year-old woman comes to the physician ...
Inferior mesenteric and superior mesentericπŸ”

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submitted by deathbystep1(14),
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lal eht ohetr essvels, heirte vahe leltalorca usplpise or htye spyupl ot gsaonr twih tliulemp rescuso of bdolo lsppuy

IMA nda SAM othb evha secllloaart htiw ache rothe amgrla(in rrieesat nda madegirnen aeers,r)it os nacies eetrh is lvvteoeminn of noe fo eht sirreaet hte ldoob spluyp omfr ohtre anc rveenpt sce.mhaii

utb if btho SMA adn MIA rae lvnvoied ti duowl ulerst in haiiemsc adn ptmmossy eebrcsdid in eht

paperbackwriter  Spot on! +  

submitted by cocoxaurus(56),
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eTh tenprtonseia erhe smsee ot tfi atth of cenirsemte aclasrvu oulicnc-os panadoslirtp pian tath aslts 1 oh,ru dofo oinaesrv, thigew heT inetpat soal ash isrk stcfoar adacessito wthi teiercnems sruvaacl -cusliocno rloed tahn 06 seayr ,dol ieHameil,rpdyip ,etHienpsoryn MH.Px

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tsllCeraloa bewtnee SMA nda MAI erna het nilscpe xreelfu dr(ingeaeMn nMesceeitr e)y.trar erTeh si aslo lelalcorta neebwte ilecCa Ayterr nda MSA aentoaocradnPecdlu(i arecd.)a

Layl,ts I nokw that teerh is a cm3- ccateti aarot fdnou on CT, utb an icraot anueryms ldwuo not rudcpeo eseth .tsmpsomy enEv fi yuo ohgtuth htta eht ytsspmmo weer eud to eht ,AAA yuo duocl llsti egt ot teh trceorc eawnrs fi uyo eus msf'd1hae4 ngesn.airo

honey-crusted lesion  Great explanation! There's also a slide about this in the 100 Anatomy Concepts pdf but doesn't go into as much detail as this explanation. Thanks! +  
djtallahassee  Good explanation but I think an AAA would be more likely superior mesenteric and hepatic. the SMA and IMA are more than 3 cm apart (L1 to L4ish), Triple A affecting both would be very large. I blew this question because I saw 3cm and jumped to AAA, didnt even see it was a sclerosis thing. Put the two closest arteries and moved on +  

submitted by fahmed14(29),
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Teh c3-m ccaiett atora sname hse sah an lodmniaab tocair rnusy.ema ayn,eerlGl ehyt entd to rcocu owelb eht lrane nhecrsab os I etwn whti the wto eolssct hrnsa-bec ASM s(htiylgl boeav )nlare dan IAM b(eolw A lr)n.,slaoe nlecpis rulexfe si a nmoomc heedraswt aare ipslepud by SAM nda IAM os nivveotenlm fo obht nca ecsua her mtossmyp

submitted by usmle11a(73),
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teh lony nigth daem em csoeho IMA nda MSA si het afct tyhe ypsulp het nsetitien ihwch si eht momcno etsi rfo mciescih icreetmens i.sseead

submitted by brethren_md(88),
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crnoCih etinsMrece hicaesIm aak nitetlisna nnaagi. inMa slecu are agaloistrpnp episcgaitr n,iap tgheiw oss.l usylUla due to aCceli ,)a( S,AM ro AMI .issratlheosroce

neonem  What's tough about these answer choices though is that you have 2 different viable combos. +  
codyluvr95  The ectatic aorta might also mean AAA below the renals, affecting the IMA, +2  
sherry  Also since there is this ectatic aorta, the arteries involved need to be adjacent to one another. If there is a choice as in celiac and SMA, it could also be correct. +  

submitted by targetmle(6),

if the option had SMA and celiac trunk, would that be correct?

submitted by bharatpillai(22),

One way to look at this would be to go back to pathogenesis of fatty streaks. They are most commonly found at the aortic bifurcation, so basically the lower down you go down the abdominal aorta, more turbulent the flow, causing higher potential for atherosclerosis and stenosis of branch vessels. Also, renal artery stenosis is well described which is given off after the celiac trunk so safe to say celiac trunk is spared in any kind of atherosclerotic stenosis.

submitted by ankistruggles(14),
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Why aer the IAM dan SAM tmos lkiely to eb fedtcafe ni ehr o?itncdino

sattanki  Again, not too sure, but I think they were describing a patient with chronic intestinal angina, which is classically from atherosclerosis of the IMA/SMA. +3  
mcl  I was also thinking about which areas have crappy blood supply (watershed areas), which I assume would be worse off in the case of chronic mesenteric ischemia. If you look on page 357 of FA 2019, SMA & IMA at the splenic flexure is a watershed area; the other is rectosigmoid junction (sigmoid branch from IMA and superior rectal). +  

submitted by mousie(211),
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lnooigk abck at shti Q I icotne tath teh tpintea sola hsa tpnnreeyhsoi d..olcu. taht vahe enbe a eulc ot udlince het MSA bc its os olcse ot the aerln erasetir eR(nla a ?sstsi)eon

nwinkelmann  I didn't know how to approach this either, but now this is my thought process: Patient has pain after eating. If it's not due to an ulcer (which is the only thing I could come up with because I didn't know what else it was talking about), why would eating cause pain? Well... eating causes increased GIT activity which means increased blood flow. As you pointed out, the patient has HTN and CAD, indicating likely extensive atherosclerosis. This is important because why would eating leading to increased blood flow cause pain, when usually it doesn't? Well... atherosclerosis in the heart leads to stable angina. This presentation sounds like a "stable angina" of the abdomen. +