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NBME 21 Answers

nbme21/Block 2/Question#43 (37.4 difficulty score)
A 78-year-old woman is brought to the ...

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submitted by visualninjacontender(17),
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194orbust  why would an embolectomy be favored over clopidogrel? +3  
194orbust  oh's bc clopidogrel won't bust a clot, just prevents them from forming. +17  
chandlerbas  also the way i see it is the hommie has so much pain as indicated by "sudden onset of severe pain" so you want something fast and effective. surgery time! grab my scalpel! drugs could be indicated but arent an option even then heparin takes 20 to 60 minutes to work so +2  

submitted by zevvyt(32),

to me, this is a process of elimination question.

Fasciotomy and bosentan don't make sense.

Clopidogrel and aspirin kinda make sense, Except Treatment of DVT is not part of their clinical use. (Clopidogrel 429 and aspirin 475 of FA 2019).

So we're left w Embolectomy.

PS. Thrombolytics and Direct Factor Xa inhibitors are used for DVT

personalpurposes  Yeah I dont think is going for a DVT though, the patient is presenting with "coolness and paleness" in her LE with absence of pulses". This is basically implying an arterial occlusion and thus an embolus in the ARTERIAL system. In a DVT we can say arterial supply is normal so we would feel a warm extremity with normal presentation. Either way I guess at the end of the day you could embolize the DVT clot too. +1  
yhm17  And the mention of irregularly irregular rhythms clues you in that a clot was formed in the heart and embolized to the lower extremity arteries. +1  

submitted by an_improved_me(16),

Initially i was stuck between embelectomy and fasciotomy, mainly because the pt did seem to have some symptoms of compartment syndrome: pain, pulseless, pallor, perishing cold (remember 6Ps) so i thought maybe fasciotomy could be an answer.

However, fasciotomy is something that would usually occur due to neurovascular compromise, which commonly happens from trauma. So i went with an embolus, since the pt had irregularly irregualr rhythm, prediposing to thrombus/embolus forming, with eventual occlusion.