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NBME 21 Answers

nbme21/Block 1/Question#25 (47.1 difficulty score)
A 28-year-old man is brought to the emergency ...
Dissecting aneurysmπŸ”
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 +7 
submitted by neonem(570),
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aoMjr rski ratcof ofr artico odtsnecsii si eon,istryenhp adn ni stih ecsa ghtmi eb due to caoicne ,seu hwich uecsas erakdm o.phseynertin isnsDsiotec acseu a eatr ni eth ctiuan mtiian -- obodl can flow kaadcsrwb otni het ucirremaidp nad caesu nape.oadmt hTsi aenmisfst sa aslceckr ni eth nglu ued to opor ftle ulriatcvenr tfninuoc lcaosigll/i(tdiifn molbpre ued ot nmrpo.sc)ioes

forerofore  there is another clue, the man has diminished pulses in just one arm, which means that the left subclavian artery must be involved somehow, and an aortic dissection would be the best answer explaining this. +9  
temmy  please why is there where a diastolic mumur? +1  
whoissaad  @temmy Aortic dissection especially near the root of aorta can lead to dilatation of the aortic valves, which can lead to Aortic regurgitation (diastoic murmur at left sternal border) +8  
garibay92  Does anyone know why is this patient's tepmerature elevated? +1  
ratadecalle  @garibay92, not important for this question I think but cocaine can cause malignant hyperthermia +1  
almondbreeze  judging by his heart murmur, he probably has marfan syndrome. that's the only place where FA talks about dissecting aneurysm +  
almondbreeze  he's only 28 - another clue for marfan? +  
turtlepenlight  did anyone else think it was weird his only sx was SOB? I always think of radiating pain as being a good clue for dissection +2  
cmun777  @almondbreeze his heart murmur is at the LSB (aortic regurg) and not consistent with MVP plus no other sx/indication of Marfan. I think the only association of RF you should think about in this question is the cocaine use and consequent HTN. +1  
ibestalkinyo  @turtlepenlight I agree. I chose another answer because I was like, there's no way this guy doesn't hurt if he's got a dissection. +1  



 +0 
submitted by adong(97),
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qenuual pelsB/usP in hte masr si a gbi yek for ritcao ctsindsieo




 +0 
submitted by readit(14),
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yhW si si ont opdues uyrna?ems

oi"cAtr muodsyaspenresu yicplytla ocrcu as a lrteus fo aarumt -+/ ttnevi,inonre a eeicsorddn utsebs of tacimtura ractio injuyr ni hte arijtyom of s.esac hTye acn eb uacte or irhcocn".

urnrasge?//:cyionstum/assd=orahpcirges.-leaatilaett/aoiudrodpp

readit  *same goes for saccular aneurysm, which also is usually 2/2 trauma +  
samsam3711  In the question stem there is no indication of trauma so it would be hard to just assume that +  
almondbreeze  see my comment above for marfan syndrome. might help +  
drzed  This is because a pseudoaneurysm is between the media and adventitia, and is incited by trauma; a dissection is between the intima and the media and is a result of hypertension causing an intimal tear. The history points toward cocaine -> hypertension rather than penetrating trauma. +  



 +0 
submitted by meryen13(18),

just remember that cocaine is one of the common causes of aortic dissection in young people. there are other causes that are genetic such as marfan, but in this question its clearly mentions cocaine abuse. the pain of dissection radiates to the back and its sharp. widened mediastinum is also a key.