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NBME 21 Answers

nbme21/Block 3/Question#12 (43.8 difficulty score)
A 55-year-old man with hypertension comes to ...
Left renal artery atherosclerosis🔍

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submitted by pg32(152),

NBME/Uworld love to test renal artery stenosis in the setting of hypertensive urgency/emergency. Just because this has been done so many times, you can basically get the right answer from the first half of the question. Pt with end organ issues (headache, confusion) and really high BP (I know it isn't 180/120, but it is really high). So this guy basically has hypertensive emergency. I'm already thinking it's renal artery stenosis. Next sentence? A bruit over the left abdomen. Bingo. Renal artery stenosis, most often caused by atherosclerosis in older men (as compared to fibromuscular dysplasia in younger women).

lovebug  He is heavy smoker but, No weight loss, No cachexia -> so can be R/O Left renal cell carcinoma. is it right? +  
lovebug  Renovascular ds. FA2019, pg 592. +  
misrao  and no hematuria so r/o RCC +  

submitted by necantoramericanus(2),

Im tno leyral sure but I tnkih hte noitp is taht ithw hte oparpitcl naeudciriodl nacs erhet is a ydlae ni iuotfncn of the yndek.i htaW ehyt ewdtna us to mmeerbre here is hatt hwen uyo giev a " A i"rpl to a pttneai ihtw enlaR rtayre lcoesstireaoshr eht alnre nuctonfi rwensos bueseac reeth si cnnrtcosioti fo hte ereenfft orlertaei

FA 0128 - 756

kevin  efferent dilates with an ACE-I due to loss of angiotensin mediated vasoconstriction +  

submitted by usmleuser007(396),

Jstu edrlizea thta nreal ecll nmiaacorc in'ts eht crrtcoe ansrew cb/ ti edainvd eht oevsun rniolcautci and tno hte .ritreala BP yam ont eb etcadeff sa .chum if CRC wree teh nerswa ethn tnhe eehtr doulw avhe bene eeadm sterenp nadro/ alren .NTH

sympathetikey  Also, just thinking out loud, in the case of RCC, it's the kidney tissue that's dysplastic & moving, so technically the renal artery itself isn't dysplastic, right? +  
paperbackwriter  @usmleuser007 very good point regarding the venous vs arterial circulation that I neglected to consider! +  

submitted by rainlad(23),

oHw do we lxapnei the irbut in stih sa?ec sAol ywh stn'i it ltef atrrye amsnru?ye ahtT esems lkei ti wuldo rteebt xpeanil the ubrit

gdupgrant  The bruit is basically just turbulent flow, which is most commonly caused by artery narrowing. I was just reading on renal artery aneurysm and it looks like most of the hypertension is actually related to a pre aneurysm stenosis, so i think stenosis is the "better" answer, esp. since the pt has like every risk factor for stenosis. To be honest I had not ever really thought about RAA for this case because bruit over RA has been drilled into my head as renal artery stenosis, but i apprecaite seeing how this is a super reasonable answer - just the stenosis is "more likely" +1  

submitted by usmleuser007(396),

oFr :RCC A(s rpe LRWO)DU

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eTh rnbocusiott can rcuoc autylec or grulalady veor tie .m In ircncho sesac, lrltlacaeo vuseno icorintluac may ovepedl dsabe on the tesi of eth iuncbos .ttro irtoePnnm anobmdial lercoatwllal al i,sven as ni isht tnip,eat ggstesu tusbcoitrno fo hte prpue megtnse of hte .IVC

nor16  high blood pressure, i.e. Hypertension, risk factors for atheroscl., bruit !!! over left abdomen, secondary art. Hypertension. they always want the renal artery stenosis (like vWF in coag. disorders...) +  

submitted by jackie_chan(19),

I approached this question because man with rather extreme HTN and abdominal bruit is quite often renal stenosis

ALso captopril renal radionuclide scan's function is literally to assess renal stenosis (looked it up, but i did not know that when i answered)