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NBME 21 Answers

nbme21/Block 3/Question#16

A 16-year-old boy is brought to the physician ...

Exercise-induced asthma

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 +9  upvote downvote
submitted by liltr(14),

I choose MVP too, but this patient’s main symptom is cough only during exercise. This is more indicative of exercised associated asthma. You could see shortness of breath in MVP during exercise, but choosing MVP leaves the cough unaccounted for.

.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. +8  
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" +3  
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? +1  
cienfuegos  Just noticed that he has FHx, game changer. +  
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) +  
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. +  

 +3  upvote downvote
submitted by lnsetick(47),

I just remember Sattar saying MVP tends to be asymptomatic. Also, I think the kid complained specifically of coughing, and that made me really lean away from MVP.

yo  he also has a family history of asthma. that's shit is genetic. +1 for asthma. +1  
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 moo(0),

if the lungs were clear to auscultation and the kid even said he doesn't want to be on the team anymore why couldn't it be malingering?

amarousis  malingering would be a conscious faking of symptoms to avoid being on the team. he wouldn't have the mid-systolic click and he would probably complain of his symptoms all the time and not just limited to during exertion. +  
temmy  malingering is also doing it for some external gain. which was not indicated in the stem +  
garibay92  Also, patients with asthma are usually asymptomatic at the time of physical exam unless they are examined precisely during the attack. +  

 +0  upvote downvote
submitted by readit(4),

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".)"