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NBME 22 Answers

nbme22/Block 4/Question#31 (33.4 difficulty score)
A 65-year-old man comes to the emergency ...

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submitted by usmleuser007(397),
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stJu noet hyw heort srnswea ear ont ccrr:teo

  1. i&oEos;nhbnpypsg na cnresaedi ceesonran of vcieo oudsns redah hwne sacntuiultga het lgsnu, ftone esucda yb nulg aoinsloiondtc nda .srsfiboi

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  2. eWepsdrih ulbopeqsstn;oryecrf&pire to an crdeesian osesdnul ediprhonbn;&ntgop;nsiwefsspb& duirgn iltatcsouanu whti a sshtoeetcpo no teh ulgn sfelid on a itta’npse to.rso

    • .a yUsalul snoepk nsdsou fo bnpseavmuped&p;hiso&slnrbwe; yb eth ttnpaei udolw tno be eardh by het acninliic giausluctant a gnul filde tiwh a p.teshoecsto

    • b. eHvrw,eo ni esraa fo eht glun whree erhte s;nsn&iglubp aoonnsdoiil,tc htese pwidsrehe senkop snodus by eth tanipte shc(u sa nayisg nn’eti)-eiynn‘ lwli be leylacr dhera ugthorh hte .poshtseoect

    • .c Tshi incersae ni snoud sestix ecabeus odusn rstvale sfrate dna uths iwth rewlo osls of iiteynsnt rtoghhu iulqdi or oisdl df“(liu ”ssma ro d“islo ,”msas l,iyrtvpeesec in het lgn)u svrsue sugseoa (ira ni eht ul)gn aedim.

    • .d dreWieshp tceyrqouilpo si a nillicca ttes apylclyti pomrerefd dungir a ceialmd pshcilya enaiointxam to ulatveea rof teh npceesre &unbsgn;plof nosoanctdil,io ciwhh culdo be sceadu by ncrace (soild asm)s or uonnaempi (ilfdu as)ms.

titanesxvi  why not wheezing? +  
miriamp3  @titanesxvi because the dx is CHF +  
leaf_house  I get why crackles are more likely in CHF, but wouldn't it also cause whispered pectoriloquy, if fluid allows better transmission of sound? +  

submitted by asharm10(26),

S3--> dilated cardiomyopathy (eccentric)--> systolic failure--> blood builds up--> increase hydrostatic pressure in pulmonary vessels--> exudate--> crackles

submitted by taediggity(34),

2/6 systolic murmur over the left sternal border,an S3 (increased LV filling), low 02 sat, figured this patient had hypertrophic cardiomyopathy and early signs of CHF, so the answer was crackles from the pulmonary edema from fluid back up from the HF as brise pointed out below the 1st comment.

samadmom  I believe this patient actually has dilated cardiomyopathy (as opposed to hypertrophic) due to his age, HTN, presence of S3 (hypertrophic usually has S4), and also his murmur. The murmur indicates mitral regurg, the tip-off was "radiating to the axilla". Because the stem states that the PMI is diffuse this can lead us to think that his heart has enlarged in an unpredictable way (ie. making it acceptable that the placement of the murmur is different from where we expect). Lastly, secondary mitral regurg is an indicator of poor prognosis for HF. Once the ventricle has dilated to such a point, the mitral leaflets are unable to properly close and perpetuate the backward flow of blood. Hope this helps! +  

submitted by zevvyt(32),

You dont really need to know the murmur to get the question right, but I'm confused about the murmur. It sounds like Mitral Regurgitation. So why is it in the left sternal border and not the apex?

submitted by nootnootpenguinn(7),

FA 2019 page 306, under "Heart failure"

"Clinical syndrome of cardiac pump dysfunction --> congestion and low perfusion. Symptoms include dyspnea, orthopnea, fatigue; signs include S3 heart sound, rales (aka crackles), jugular venous distention (JVD), pitting edema."

Yeah, I forgot that rales = crackles... why can't they just stick with ONE terminology... anyway. Hope this helps.

submitted by mattnatomy(43),
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ekCcslra ehriet cnidisate onrcchi orcbnshtii or oaosnlionidtc (mfor oiauenpmn ro nlprumoya dmee.)a

eviGn hatt hster'e ylno a 1 ayd yortihs of B,SO 'mI lnnagie reom toawdsr broal en.uomapin eaybM 'astth loas s'ahwt gnciaus teh S3 at teh LS?BL If sti' athSp se,Auur I ssueg ew coldu be likogon ta cuaet soraeitidcdn + m?napinuoe Or Q Fve?re utB ha'stt ujts elcuo.aisptn Culod sola tujs be atth het ugnl oolinsdaoctin si ieglnrat odlbo fol,w dieagln to teh kcba up nito eht hgiRt tmriAu &pma;

brise  Patient has CHF from the S3 heart sound and has MR. You hear fine crackles in early congestive heart failure. +15  
usmleuser007  No Infection - normal temps ; Q-fever presents with A patient with exposure to waste from farm animals who develops: a. nonspecific illness (myalgias, fatigue, fever [>10 days], b. retroorbital headache) c. normal leukocyte count d. Thrombocytopenia e. increased liver enzymes +  
saulgoodman  This patient has CHF. But it kind of sort of seems like he's presenting with a PE. +