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NBME 22 Answers

nbme22/Block 3/Question#38 (61.4 difficulty score)
A 73-year-old man comes to the physician with ...
Blood pressure🔍,📺

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submitted by madeforupvoting2(14),
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PAPC ressienac petulalrirna esesrrpu sa the evedtael iraawy eurssepr si satemttdnri ot troeh sitghn in hte ciyvat ugl(n phsesu on ralpule tccse/apyiav wcihh acn hnte psuh on rtheo )ercuut.ssrt hiTs anc dale to oosmpnrices of eni,sv iiudngcln the vaen vaac &;t-g sdeeadecr vnoesu ntuerr t;&g- deaesrdce bp rm(of eecddares ldroae).p Tihs is miairsl ot atwh pesaphn grduin llvasaav eiorxen(t pssah)e uothgh teh vespioti uerssrpe si rpeddvoi by a meihacn uppm sntdaie fo lmadonbai ghilmr./cmusadsepa I kniht aetrh reat elkily ssaenirec instdea fo rdsaceee as a yercnsoaptom onrpeess.

eeHs’r one teis ttah nesilpxa ti ewll e(th re”e“f ocetnnt is hgueno dna ylabrbpo aerdyal edescxe eth pthde neo gmhti eend to wkon) neacexl/-tlyprcim/hit/fikfasnpateenah.otauhiltt-socor-e-:onamecf/omtyccrv

dodgerslakers15  Pulmonary physiology is not necessary here. The root of the question is asking what will improve over time with treatment of sleep apnea, which is blood pressure, given that sleep apnea causes increased sympathetic tone and therefore systemic HTN. The treatment of sleep apnea with CPAP, will help reduce sympathetic tone and over time, improve BP. +10  

Guys don’t forget that in OSA, periods of apnea results in increased sympathetic tone, hypoxia causing pulmonary hypoxia vasoconstriction, thoracic movement without inspiration increasing negative intrathoracic pressure ==> all these factors leads to hypertension in OSA.

To remove all this we give CPAP, which results in decrease in BP over long period. (It is not only about increasing intrathoracic pressure and reducing BP)

+13/- apurva(82),

submitted by drpatinoire(15),
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suyG I evah aoerhtn o.thtuhg

viGnig otreh ecochis are atbuo hsi hetor nrolabma vaelsu aes(cdnrei ,nertaeci legous,c ruic c)d,ia I ssgue teh itnesqou is setgnit us whhci fo shete avsuel lwil ovimrpe fi ihs OAS is mvrepdoi yb .PACP

icenS OAS si eon of het mots nirmpttoa uesasc of doiiaihptc nentiysreho,p ti udolsh ocme to su htat econ ish SOA si atetde,r his peinetrnhsyo lilw vmrepio oosn.

So se"edceadr B"P sadeitn fo oreht rbanolam .seluva

s(akThn to ym rinfsed rfo ingihtn em otbua )ihst!

dodgerslakers15  This is the correct way of thinking about this question. ^ Pulmonary physiology is not necessary. The root of the question is asking what will improve over time with treatment of sleep apnea, which is blood pressure, given that sleep apnea causes increased sympathetic tone and therefore systemic HTN. The treatment of sleep apnea with CPAP, will help reduce sympathetic tone and over time, improve BP. +1  

submitted by meningitis(574),
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oAhulthg sti’ atobu ,PPV ihst ereicsnargh epdlhe me dednutansr ibcsa y,hsp I eoph shit hpels ervenoye ni osme a.yw

k:aeTaywa uiDrgn PPV, eonuvs untrer eedescr,sa acarcid tuupot d,casseree dan rteah seessurpr aseceder ni eth trghi dsei of het hetr.a

Why osde VPP eecrased vesnuo te?rnru

  • itcacnoirhtra uspsrree eomsprescs etra,h cngisau odolb ont ot ntrrue

esCusa rfo sraddeeec telf navruclreti tupuot unirgd eaontviitn:l

  • tfhinigS fo tceiraavntnrluri upemts ot Lfet eud ot rnedeisac VR uevmol
  • ecsaedreD eousvn rtuenr
  • haesgCn ni arhste ailbyti to ontctcar edu to pvtieois susrpree
  • ackl fo O2 to ather

rNlamo ayroocsempnt sneicmhams fro nmniiigtana CO adn PB unridg PPV?

  • eeaicrsdn RH ot cemetpnaso rof raceedesd SV
  • dinseeacr VRS ot ntmaiani BP

trehO sgloPyihoci n:eeopsrss

  • Daedreces eeracblr nespifrou resreups dbs’o(y resospne ot a afll ni PPC si to risae csstymei bdolo rseesupr and diteal rcerleba boold esvels)s
  • srdceeaeD reanl sineuopfr dsIrcenea( HDA, SA,RA dna nteitaP ash rlane lemoprbs os seceanrdi enaicnietr dan ruci cid)a
  • bslesPoi nlatnrimutoi sei(nacdre lcgoesu iav olgnssegeenucoi tce.)
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +30  
drdoom  looks good to me! ;) instead of asterisks try using the plus sign for unordered lists; the system gets confused sometimes because the asterisk is also for italics 😊 +1  
meningitis  Yeah, I noticed :s Oh, I didnt know the + sign did that! Very much appreciated, I will try that next time. +1  

submitted by trump2020(7),

You guys are way overthinking this. Chronic hypoxia causes hypertension due to SNS activation and EPO production.

teepot123  yep +  

submitted by cathartic_medstu(30),
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Cna sonemeo rcctore my snrgnaoei he:er

I saw tnkhiign svpiotei rwyiaa rrespesu iwll raensice aollvrae lotiietnavn adn seeeradc xyaipoh iuddcen uolypmarn aorviccnttios.nos u,sTh VR aftre odal ulowd eeaecsdr =tg&; moer leoradp ot VL and eorm ciaacdr .putout heTn tul'dnwo BP seacrde?e

nyA hlep si .pcedreipata k.nTsha

pg32  I just thought of it as follows: he has high BP due to pulmonary vasoconstriction as well as widespread sympathetic activation (as if he is being partially strangled all the time, because he basically is). Increasing oxygenation will relax his pulmonary vasculature and decrease sympathetic stimulation throughout the body, leading to a drop in blood pressure. +1  

submitted by noselex(6),
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I eundnstrad eslpe anape wudol asuce ihapyxo dan eraiscen in NSS yi.aivtct So tttmaeern wldou edceur BP and aterH eaR.t I aws tskcu eenebtw hte owt ti.pnoso Why was the arenws lobdo susrerpe dan not H?R I gdeolgo onaurd a tib and fnudo uestdsi hatt hows drop in tobh HR dna .BP I ugsse PB porsd mreo? Cna omneoes lseape

madeforupvoting2  CPAP increases intrapleural pressure as the elevated airway pressure is transmitted to other things in the cavity (lung pushes on pleural space/cavity which can then push on other structures). This can lead to compression of veins, including the vena cava -> decreased venous return -> decreased bp (from decreased preload). This is similar to what happens during valsalva (exertion phases) though the positive pressure is provided by a machine pump instead of abdominal muscles/diaphragm. I think heart rate likely increases instead of decrease as a compensatory response. Here’s one site that explains it well (the “free” content is enough and probably already exceeds the depth one might need to know) +3  
apolla24  I guess since changes in HR are such a transient phenomenon and you only have sustained increase in HR when exercising or like acutely experiencing some medical emergency vs BP that can be elevated for long periods of times with no effects. Therefore an improvement in BP is more important. That’s my take. +  

submitted by welpdedelp(242),
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csanedeIr cnniaaarrlit suseerrp ttah tslsuer in hnsuCsig' drtai fo asercdine dlboo rseu,srep ageilrurr ,tabirgneh dna dayrraibac.d hTus, ihhg CO2 nuesdci gsnucih aidrt and if uyo gevi PP hetn ti liwl cuededr 2CO, dan hnte wdno etaerulg eht spehtmticya oocns.oivtitanrsc rilnayOlig teh arinb hda os cumh C2O tath it zedzsap uot dna rteid to enracsei hte PB ni edrro to husp oerm dxoteenyga olbod to het


lispectedwumbologist  "Bradycardia" 84 bpm lol +  
lispectedwumbologist  The hypertension in obstructive sleep apnea is due to increased sympathetic tone not increased intracranial pressure lmao +1  
meningitis  @lispectedwumbologist : Be mature enough to correct him/her and move on, not laugh at him/her. +14