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NBME 22 Answers

nbme22/Block 1/Question#1 (102.4 difficulty score)
A 66-year-old man develops worsening ...
Dilution of serum sodium due to ADH (vasopressin) secretionπŸ”,πŸ“Ί
tags: RAAS 

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submitted by imgdoc(135),
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I hiktn olta of epopel mtihg ahve revo mdesipeazh who oiptatrnm NAP dna PNB elrayl rea, sye it is otmnpiatr to ownk hetse dpetspie etg esrtdeec yb hte rlvieaitucltar/nra odurciymma uirngd traeh rlif.aue evwHeor heirt arollev fvcteeifneses ni rnteiagt htrae uafleir si chl,zi a ptprceero oltd me htat if APN dan PBN wree os suelfu in eairnrtissu nteh yhw do we geiv tidsu?crie st'I ceaseub ARSA rsovewoerp hsti yetsms cehne cigasun aevntgie seftefc nad hte eesnlds loop of tarhe .earfilu KAA why ew iveg CEA .itihobsnri

wnnoigK hatt PNA gset arzeuldnite yb eht AASR esyt,sm ew cna ihfst ruo sfouc cbak to rheat lfieaur in ihst p,titane wrehe aaidccr utuopt si ,redsacdee egianld to HDA senircote and nlyalfi ndtlualioi rhmieyn.aopat

almondbreeze  a concept continuously emphasized by uw, but I get always wrong :'( +2  
almondbreeze  good work done! +  
raffff  why does the body make anp at all since its so useless +3  
makinallkindzofgainz  @raffff - at least BNP gives us a good marker for heart failure exacerbations :) thanks body! +  
mannan  Yeah it's important clinically because it has a high sensitivity (if negative, rule out) for Heart failure. +  
alimd  At the same time ANP inhibits renin release? +  

submitted by meningitis(546),
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I olsa ugtothh the esam as ,ebblbu@s but wno iyngrt ot jify""tsu htis rctiky MBNE :quietosn I nthik htis eerovlsv on eth atfc ttha hte nttaeip sah a IGHH lobod ueesrsrp niemnga ew uhldso ofcsu on an nwsrea htat nlipexsa bhto driencsea BP dan lyevHmipooa i.:(e arsncidee DHA wihhc sasrnvtoosictc and olas orssabb aeweet,fr-r tohb fo chihw srnceeai PB dan ecsua olpoiy.e)mvha

byaMe fi siht teiapnt weer dednpamecotse with OWL P,B noe oludc hktni oerm uobat N.AP

I tslli tihnk htsi iuoensqt si TOO k.crtiy

meningitis  Sorry, hyponatremia* right? +  
mantarayray  I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia except only thought this post getting the question wrong :") +4  
mantarayray  Oops sorry the formatting is confusing: I think that it's not ANP because ANP will cause a loss of Na but water will follow (they usually go together), whereas ADH will cause absorption of only water and will cause hyponatremia. +2  
pg32  @mantaray pretty sure you are right and that is the only way to get this question correct. Remembering that Na concentration really is a measure of water balance is key. If the pt is hyponatremic, that just means they have too much water in the blood, which is caused by ADH. If the patient was hypoVOLEMIC, that might mean they are losing too much Na. This is illustrated by pts with SIADH. They are hyponatremic, but euvolemic, meaning that they have too much water (hyponatremia from the ADH) but their Na balance is ok (due to excretion of Na via ANP/BNP) +  
avocadotoast  We need to be thinking about how heart failure is a condition with a low effective circulating volume. Our patient had an MI and now his heart cant keep up with the volume (low CO), leading to congestion. When congestion occurs, water is pushed into the interstitial spaces and isn't circulating in the arterial system. For that reason, the body ramps up the RAAS and ADH despite an actual increase in body water. This is a non-osmotic release of ADH. At this point plasma sodium levels are determined by relative intake and losses and hyponatremia is common in these patients because of that. Also, ANP and BNP don't hold a candle to the RAAS. +  

submitted by nwinkelmann(297),
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eLki omst trheo uescsa fo nihapytrae,om traeh uelrfia misirpa the ilyibta to xceeret dgtinese erwta by enniisgrac idaritutncei oonhmre sl.lvee enhW airadcc utoutp dna sceistym dolob seepsrru rae udcreed, eooy"pvmc"lih nh,soemro uchs sa nenri hiw(t a eusesnqbut niaeescr ni etisnanoign II ria,tfonom) inictrudetai mnohero (DH),A and nepe,errininpho sonerpd ][-.13 uAgtohlh eeusmtado ispattne thiw rhate uieralf hvea enrscedia aalmps nda laexrcurtlela uifdl les,uovm the bdyo evpecsrei elvmou oletpneid eeddcru( ifecfetve iatarrel lodob eolu)vm inesc het lwo iradcac ttuoup cedreaess teh sresreup infreupsg het eocserrtoparb in eth itoacrd siusn nda eht arenl nreteaff r eredge fo arreomuolunh aitaivotnc is erlalegyn laeterd ot the eieyvrts of iaacdcr odtnyfucnis, as sedsesas by letf crrtnaeluvi noietcej tinrafoc ro oultncifan aslsc ]2[. The aourmornuleh neahscg iltim tobh sdioum dan weatr ineecxtro ni na etpmatt ot rnrteu rpesuoinf rressupe ot .ranolm DHA eeralse cleytdir achnsene awert orraiobpsnte in eht lolgtniecc sbtleu,u haserwe ongnieaistn II adn onppiineherner litim sltdia etwar vyeriled da(n hyertbe rewat icenr)exto yb nlgeriow teh elrlaoumrg altrfionti aert e(ud to a darekm odnuticre in reanl fnespr)iou dan yb rgacineisn piaromxl iodmsu nad trawe tanposeiorrb []4. In tiaino,dd btho teh wol draciac tutupo adn ghhi aisgionntne II llvsee aer neptot ilmsitu to ttrhis, ldgiean to canehnde weart i.ktean


submitted by bubbles(70),
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hTis eqonstiu oufdcsne em a olt ucbseae so myna ienoqusst vahe relldid em no hte crapoetnim fo eth NPA espace hicasmmen ni timse of fluid vderaolo as( in )HF.C

I uothhgt NPA was a gueh yaprel ni hte loss fo Na ni scnueimsccrta fo oveuml oreadolv sa ni sith enitatp cw(ihh si wyh yuo see oimuvecle etryamOpaihn in stinepat wthi DASHI ro rvitytivocae fo teh AARS sa ni .H)CF

hWy is HAD onw eingb maedn sa eht sbnspoerlie gn?eat

jooceman739  My thinking is that ANP causes natriuresis, so you're losing salt and water at the same time (isoosmotic fluid?). Meanwhile, ADH absorbs only free water, so it would dilute the serum. Correct me if i'm wrong. +10  
bubbles  Ohhh you are right. Thank you for the explanation! I got so fixated on that one mechanism haha. +3  

submitted by dr.xx(153),
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HFC pitestan tnfoe apylsdi isngs dna msoymtps of iedeasrcn snesoparvis ener.otcsi

hyperfukus  if all else fails i hope i just drill this one statement in my brain and it comes out in the right way on test day thank u!!! +  

submitted by moloko270(66),
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osn"ydmer fo laounti"dli imyllo-"yootashp ni ereesv egsotivenc ehrta rfeiula may be ceuads yb na tnpyroelaapirpi gihh DHA trieceson ni iwchh hte tsooreerpmoc tssmey is nieoddmta yb rmoolanson usmitil"

hayayah  Apparently, in chronic CHF you see hyponatremia. Because CHF causes a decrease in cardiac output and circulating blood volume, which in turn triggers a compensatory response aimed at preserving blood pressure. This stimulates the body to retain both water and sodium. +8  
seagull  i agree with Hayayah... the RAAS system is activated due to poor perfusion to the kidney due to decomp heart failure. +4  

submitted by drmohandes(103),
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Here we og:

  • resaedcde VL ritctctaoilyn t(llbiaare serlck)ca
  • rdaesdeec cdaiacr pouttu
  • ivcteata AARS β†’ AHD
  • acneseri iyhaptsmetc vtiyctai β†’ oemr RAAS β†’ orme HAD

submitted by happysingh(45),
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i idnak of lefe o"dd" iganks isht oenustqi : tub het eittpna hda na MI 6 nmthos g,oa os yhw wdlou ti eb ynillkeu hatt he saw tdlo ot trst"ecri ,satl ttrercis dilsfu t)(rwea " ??

eussG hawt 'im kiagns si : thwa eamsk ocechi E hscu an ielykuln eocchi (,VDJ isbaa-bril esckac,rl ppreehlrai mdea)e ?

p;&ma ei@itnnmisg : hsi bp si 1/2358 Hgmm ... wyh is that "HH"GI ??

submitted by nicsar(1),
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aaHoneyrpmti rfmo Heauterilrfa p.t

tI ohldus be haoadcrpep form ertaH ua.reif

-&;tHgF sRAA ;t&g- xseeisevc toAo,lenersd H;AD NAP epcsae ,fieaur lkei corynseda lrhmeieoypt;odnrsas aerintyomHap


submitted by dubywow(17),
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tdoancDpeesem H.F akcL fo odlob olwf deu to giinlfa tearh &-;gt loewr PB t;g&- ieacsdren HDA ot niscaeer olobd eeursrsp cbka ot telbas elev.l In DHF, DAH oscetupa emtshsasioo fo noecngruiattc ANP m&pa; .PBN Tsuh, hte emtr poe"."etasmdnecd sAtacdeios twhi sstsenroh fo ahtr,eb daeme tno(ef of gl.n)us

Tsih uoiicsv yclce csnnuiote as bdoy rzoipiisrte eadetuaq BP for luvsr,via tbu ti esocm at the pxeseen of rovkeedorw eahtr tath sumt orwk aedrrh and hadre,r yllmetiaut aiacenbxretg het treha erfaliu cnn.tdiooi

submitted by asharm10(26),

Always know this Hypo or hypernatremia is because of change in the volume, this patient is going through heart failure, renal perfusion has gone down that leads to release of ADH cos of osmoreceptors stimulation. Now high ADH will reabsorb more free water that will lead to hyponatremia. So hyponatremia is almost always related to high ADH. I know few of you will think but RAAS system is activated too but that abosrb Na along with water but ADH just free water.

submitted by hello(317),
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eTreh hsa ot be a tebtre itnelxoaapn orf why ANP is grn?ow

waterloo  If this pt's ANP/BNP were causing him to become hyponatremic, why does he have fluid overload symptoms (bilateral crackles, JVD, high BP)? There has to be something else overcoming the ANP system. +