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NBME 21 Answers

nbme21/Block 3/Question#16 (54.8 difficulty score)
A 16-year-old boy is brought to the physician ...
Exercise-induced asthma🔍
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 +14  upvote downvote
submitted by liltr(22),
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I hecoos VMP o,ot utb tihs tnstia’ep mina tsomypm is ghuco only guidnr exce.eirs hisT is mroe vnaetciidi fo xerdieesc acoedastsi ma.ahts ouY cluod ese ethnssros fo ertahb in PMV dugnir re,sxecie tbu ocsiohgn PVM evaels eht ucgho uuadcetncon of.r

.ooo.   I agree! Also, At the end of the stem, the question is which of the following best explain the patients symptoms? Not physical exam findings. Since this patient is coming in with a chief complaint of SOB while playing sports exercise induced asthma is the best choice. Hopefully that helps. +12  
uslme123  I mean... couldn't increased BP during exercise worsen his MVP and give him SOB? +  
uslme123  (by causing slight regurg) +1  
yotsubato  "Lungs are clear to auscultation" +6  
sahusema  But wouldn't choosing exercise-induced asthma leave the murmur unaccounted for? +  
cienfuegos  I incorrectly chose malingering and am wondering if the fact that he presented (although it doesn't state who brought him in/confirmed his symptoms while exercising) makes this less likely despite the fact that he clearly states "I don't want to play anymore" which could be interpreted as a secondary gain? Also, regarding the MVP, I'm wondering if the fact that these are usually benign should have factored into our decision to rule it out? Thoughts? +2  
cienfuegos  Just noticed that he has FHx, game changer. +1  
kimcharito  clear lungs, they try to say no cardiogenic Pulm. edema, means is not due to MVP shortness of breath while doing sports and no shortness at rest makes me to think more asthma induced by exercise) +1  
pg32  Isn't exercise induced asthma usually found in people running outside, especially in cold weather? I feel like that is how it is always presented in NBME questions, so this threw me off. Not to mention the MVP. +  
happyhib_  it took me a little; the FHx really pushed me to exercise induced. I was also looking at malingering but there wasnt a real reason to push me to this (as a doctor it would be sad to be like hes faking it becasue he doesnt want to play sports with out being sure first; led me away because there wasnt enough pointing there). Also MVP could be slightly benign and is very common and usually no Sx and his lungs were clear as was rest of exam. All pushed to Asthma +  
mittelschmerz  I think MVP on its own shouldnt cause SoB with cough (in a question, I'm sure it could in the real world). In the world of NBME questions where you need to follow the physiology perfectly, you would need some degree of MR that lead to LV dysfunction/vol overload, and theres no pulmonary edema nor an S3 that point us towards that. Malingering would have to be faked for gain, and theres no external gain here or evidence that he's faking symptoms. You would also need to r/o physical illness before diagnosing malingering, which hasnt been done. Cold weather is certainly known for exacerbating EIA and are the exam buzzwords, but any exercise can absolutely be a trigger +2  



 +5  upvote downvote
submitted by lnsetick(84),
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I tujs mrerembe tSatra nygsia VPM endst to be atmto.yscmapi sA,lo I ikthn eth kid mdnocplaie ipcscfielayl of gcgiunh,o and ttah adme em llryae nale aayw rfom PM.V

yo  he also has a family history of asthma. that's shit is genetic. +1 for asthma. +3  
yotsubato  Cheif complaint is SOB during exercise with coughing. Mitral valve prolapse is not going to do that so I picked asthma as well. +1  



 +0  upvote downvote
submitted by readit(11),

Why it is not MVP:

Full quotation from UpToDate: "Symptoms [... such as] various nonspecific symptoms such as palpitations, dyspnea, exercise intolerance, and dizziness have been attributed to MVP. However, symptoms are not reliable indicators of MVP. Furthermore, symptoms frequently seen in individuals with MVP have not been conclusively determined to be more prevalent than in the general population. As an example, in a study of 147 patients referred for echocardiography for suspected MVP, the presence of symptoms was not associated with MVP on echocardiography (found in 22 percent) [43]. (See "Mitral valve prolapse syndrome".)"




 +0  upvote downvote
submitted by euphoria(1),

i have answered this question right, but why there is mid systolic murmur in the stem?

mittelschmerz  He also has MVP, but asthma is more likely to cause this symptomatology and he has a family hx. +1  
euphoria  Thank you very much bro :-) +1  



MVP would less symptomatic during exercise. When you exercise, LVEDP increases. MVP is less likely as the cavity pressure increases. Moreover, MVP is most commonly asymptomatic.

Additionally, this patient also has family history of asthma.