NBME 18 Answers : Block 2 : #17 = 65 yo woman, 1 week of swollen, painful knee

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submitted by i-de-liver(1),

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Deso anyoen nkow hyw isht is riUc dicA not .N goeonrrah? lAl I see ni the oimrargphc rea uei.pltosnhr sI ttha iweht leni ni eth ieldmd fo hte pciuret atth eslorvya teh hyplocmyte sodpseup to be eth esdleehedan-p rciu iad?c Or si it usacbee h'ses na lod dayl nda asuuyll peicts hsritrtiA si omfr S. uAer,su os ti wldou reom kile yb iurc adci adn ton ngoearorh csien sehs' d?reol

maverick95 I struggled between those two answer choices as well. I thought that the large needle shape right in the middle was a uric acid crystal which helped push me towards Uric Acid as my answer. I also took into account that she was older (even though STIs are rampant among the elderly) she didn't really seem to have any other symptoms or history of STI/gonorrhea. I figured with her age that she just wasn't able to excrete Uric Acid enough, and got a gout. Something a pathologist told me one time was that they put the focus of the picture in the middle of the shot. So considering the uric acid-looking shape was right in the middle, I figured that's what they wanted us to focus on with the picture. Hope this helps. +6

i-de-liver Ah gotcha! I guess I shouldn't have thought that the thing in the middle was an artifact lol... thank you!! +1

a1913 I believe it's because: 1) there is nothing given that would be risk factors for this woman to have N. gonorrhea 2) The thing in the middle is indeed an MSU crystal, just not under polarized light 3) apparently we get acute inflammation and increase in WBCs with crystal-induced arthropathies, per Table 11-2 on page 8 here (10 page document, top of page of interest will say p. 260) --> http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/9781582558752_Mundt/samples/Chapter_11.pdf Also take a look at the pics on the previous page, left column for an example. I got this wrong as well, but I definitely won't again! lol +2

cr i had the same problem, Whats about the fever?, could be present in gout? +

rainlad I think this question mentioned the patient's temp was 100.4 which is consistent with mild fever in gout from inflammation. This photo was wack though +

t123 The damage in gout is mediated by Neutrophils, so makes complete sense you see a bunch. +2