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NBME 20 Answers

nbme20/Block 1/Question#32 (43.2 difficulty score)
A 56-year-old woman is brought to the ...
Placement of the central line via the left internal jugular veinπŸ”

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submitted by monoloco(132),
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Tsih si teh onyl heicoc atth cmoes ocels ot ningcki eht hcrcioat cdt,u ycelfpicsila ta tsi lein,t eth tefl inascu.albv

kpjk  why not midsternal thoracotomy? +3  
wuagbe  because the thoracic duct ascends the thorax posteriorly, and enters venous circulation from behind. link to image: +5  

submitted by nerdstewiegriffin(29),

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


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. +3