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NBME 21 Answers

nbme21/Block 2/Question#12

A 66-year-old woman comes to the physician because ...


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submitted by nuts4med(4),

I was thinking Chron’s because of the narrowing of the lumen and the picture seemed like there was creeping fat. Now that I think about it though, the LLQ and constipation should have led towards diverticulitis pretty quickly.

suckitnbme  Also agree the narrowing of the lumen plus the pic is pointing towards Crohn's. The acute systemic sx of fever and chills is what made me go with diverticulitis (along with the hx of increasing constipation). +  
pg32  Why does the question say there is NARROWING OF THE LUMEN? Does that happen in diverticulitis? I went with Chron's at the last second against my better judgment because Chron's can cause strictures/narrowing of the lumen. +  

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submitted by imgdoc(47),

The clinical presentation is that of lower abdominal pain, fever, and chills. This alone made me think it was an inflammatory process. Also the question says there are 3 separate poorly delimited regions of narrow lumen. As far as ulcerative colitis is concerned, there are no skip lesions, it is continuous wherever it is. This coupled with the history of constipation makes diverticulitis the best answer choice.

I think it is good to note the demographics. The patient is female and old. That, along with the constipation, made me lean more towards diverticulitis. IBD usually develops in younger persons.

privatejoker  Does the obviously darkened area not point at all towards ischemia of any kind? Maybe I am blind, but I don't see anything that remotely looks like an obstructive diverticulum in this picture. I feel like I would have gotten this question correct if no picture had been provided at all because the symptoms described absolutely pointed towards diverticulitis otherwise. I actually changed my answer because of the image lol +8  
sahusema  Picture is a bullshit distractor +  

Don't this is UC or Crohns. For this question you have to have noticed the age (66 year-old). Lower left quadrant = diverticulitis of elderly & Lower right quadrant = angiodysplasia of elderly (think these were mentioned in Pathoma)

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submitted by burak(12),

What does 3 narrowin means? Is that a cause of diverticulary diseases or the result?? And what is that photo means :/

My reasoning was that it’d be diverticulitis due to the more acute history of presentation: “fever, chills, LLQ pain for 1 day.” Crohn’s should have a longer timeline of presentation; although the skip lesions made this one really tricky. Not sure how the gross pathology photograph plays in though ...

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submitted by angelaq11(18),

I first chose diverticulitis because of the history, but then I saw the picture, and honestly I wish I hadn't. I didn't see ANY diverticulum, so I thought...hmmm, they're want to "trick" me into choosing diverticulitis, but it's actually "something else"... :'( :'(

I picked Crohn’s too. I think the severe constipation over 5 years distracted me.

haliburton  i think it is critical to remember that constipation is what caused the diverticulosis. +3  

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submitted by egghead(0),

What is with the picture? I just would never pick diverticulitis without seeing a diverticulum...

quaper  I spent so long looking at that picture and thinking what the heck are they trying to show me here. I couldn't see any diverticuli, didn't see any cobblestoning, figured the dark patch in between the white patches was necrosis in the end. +1  

remember sigmoid colon has the smallest diameter (hence why Left sided CRC produces the apple core) meaning that it is prone to higher pressures in accordance to laplace' law (pressure inversely proportional to diameter) thus small diameter = high pressure = prone to diverticula formation

chandlerbas  one more thing. this question is not realistic. 5 years of constipation, with fever and chills...yet no hematochezia? ya ok there +  
chandlerbas  wait never mind, the inflammation scars the vasa recta so no bleeding. thanks for coming to my ted talk +2