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Retired NBME 20 Answers

nbme20/Block 1/Question#32 (reveal difficulty score)
A 56-year-old woman is brought to the ...
Placement of the central line via the left internal jugular vein ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
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 +11  upvote downvote
submitted by โˆ—monoloco(155)
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This is the only choice that comes close to nicking the thoracic duct, specifically at its inlet, the left subclavian.

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kpjk  why not midsternal thoracotomy? +4
wuagbe  because the thoracic duct ascends the thorax posteriorly, and enters venous circulation from behind. link to image: https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/thoracic-duct +7



 +6  upvote downvote
submitted by โˆ—nerdstewiegriffin(45)
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There can be confusion between two options:

Placement of the central line via left internal jugular vein can cause damage to thoracic duct and Placement of pulmonary artery can cause damage to right lymphatic duct. However, chyle [fat + lymph] in thorax is usually caused by the damage to thoracic duct because this duct originates from abdomen so it contains fat along lymph. Thus, central line to left internal jugular vein will be more likely to cause chylothorax

Source AMBOSS

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misterdoctor69  The question also mentions that there is dullness to percussion at the LEFT base of the chest and that there is substantial flui in the left pleural cavity. So we can eliminate R-sided structures such as the R subclavian vein. +8



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