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NBME 21 Answers

nbme21/Block 2/Question#12 (64.8 difficulty score)
A 66-year-old woman comes to the physician ...

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submitted by imgdoc(129),
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The nciillca eanrniosptte is ttah of lweor anldomiba ,pina erfev, nda This oelna dema em nthki it saw na nyalmiroatfm orcs.pse slAo eth teinosuq assy trhee ear 3 rtpaeesa oorlpy idemdltie snriego of wranor sA far as eviacueltr lsitoic is c,ednroecn tereh are no ipsk nsils,eo ti is nouontucsi wrvrehee it s.i Thsi lpodecu whit teh otishyr fo isocpiaotnnt esakm ietrviutcsiild eth bset raswen eiccoh.

lovebug  I know it's silly Q. but why not C) Granulomatous colitis? lol. thank you! +  

submitted by nuts4med(6),
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I asw inhkignt nsh’rCo ubsceea fo the gaiworrnn of het nuelm and het ecritup eemeds liek ether saw gneprcei aft. Now taht I knhit atuob ti ,tohuhg the LQL nda cpiooittnsan hsolud hvae lde dwotras cvturliisditie ptyert uycqlki.

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). +1  
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. +2  
lola915  FA 2020 pg.383 Most common area for Diverticulosis to take place is the sigmoid colon and diverticulitis can cause obstruction (inflammatory stenosis). The key here is recognizing the risk factors (>60, chronic constipation) and signs of acute inflammation (fever, chills and LLQ pain). +1  

submitted by usmleuser007(337),
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nt'oD tihs si CU ro n CoFso.rhr hits snutoqei ouy haev ot vahe noctdei eht gae (66 e arr.lLydo)-eow etlf ruatdqan = uiitceivtidsrl of erydell poLar &;wem gthir antrudqa = asaagnioydspli of dlerely it(hkn ehets rewe nmeitoned ni taP)omah

submitted by logical_champion(1),
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I thnik ti si oodg ot enot teh emahopdcgris. hTe tetnpia is maefle nad .dol T,tha lgnoa hitw eth a,oisotciptnn mdae em alen omer raowsdt tltruivcies.idi BDI ualluys vsopeeld ni unyerog

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 +18  
sahusema  Picture is a bullshit distractor +2  
lola915  From what I've seen on practice tests and advice i've gotten is that often if the picture is given along with an already complete clinical picture it's often a distractor. I also was going between ischemia and diverticulitis but then remembered that clinical signs in the vignette trump everything else. +1  
alimd  they dont give a fuck about pictures +  

submitted by burak(43),
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ahtW sode 3 wirnrnoa mesn?a Is htta a uaecs of atrdvycueriil edssaesi or eth uet??lsr dAn thwa is that oohtp snmea :/

lola915  Yes, diverticulitis causes inflammatory stenosis (obstruction) +  

submitted by angelaq11(61),
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I rftsi sheoc ctdilitsuverii ebasuec fo teh horsi,yt ubt enth I was the t,uercpi dan nshoyetl I hwsi I ndath'. I ti'ndd see ANY vecrliud,uitm so I .tug.m,.ohtmmhh yhtre'e nawt ot c"r"kit me noti oihcgnos cteiliiuirtdsv, ubt st'i tucllaay msoi"gtneh .ese."l. (': ':(

submitted by egghead(1),
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ahWt is wthi eth e?ipcrut I juts wlodu reevn kcpi uicrdvstiiteil wiuohtt igsnee a .mdlutuiier.c.v

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. +6  

submitted by chandlerbas(86),

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  

submitted by vonhippelindau(15),
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I piedck o’nhCsr oo.t I tnhik eth vreese ontciaosptin evro 5 ayser ticedartsd .em

haliburton  i think it is critical to remember that constipation is what caused the diverticulosis. +3  
lola915  Crohn's presents with +/- bloody diarrhea, not constipation +