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NBME 22 Answers

nbme22/Block 4/Question#31 (28.2 difficulty score)
A 65-year-old man comes to the emergency ...

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stuJ tnoe hwy oethr naswesr ear nto cocrert:

  1. ispbnhg;spn&oyoE na sncdereia secreaonn fo oevci dnosus edarh nhwe gtitlsnaucau hte sngl,u oetfn uedcas by nlgu ntlioosaidcon dan

    • a. tI is due to necndhea ainmnsoisstr of eqchgnhfu-yeir dunso scraso dli,uf ushc sa in onambrla nglu ,tuesis wtih lrewo nieusfqrcee terldief tuo.
  2. rsWidhpee ;srrscoeernioqu&eyfbtplp ot an naeciesrd slnesoud isfoebgwso;pd&rpistn&nbneph;n urigdn iaconuttlusa thwi a stcoeptoseh no het gnul ldisef on a tiap’stne soot.r

    • a. Uayusll posekn oudssn of nsebperu;sspeaiwmbdvpn;h&lo& by het natitpe dlowu otn be rhaed by the liiniancc gnuuitsaaltc a lgnu fdeil whti a s.phetetcoos

    • b. eo,evrwH ni esraa of eht nlgu hreew etehr g;ipu&lsbnsn it,oiacdlnoosn tehes eeprshiwd nokeps ousnds yb the teniatp c(hus sa nysiga )ietn‘nynni’e- will eb clreayl hared rhouthg teh

    • c. iThs eenircsa in ounsd sstixe eecusab ousdn retslav etsfar and uths with wlroe sosl fo sietinnyt hhotrgu qduiil or odsli (fl“dui ”smsa ro osidl“ am,ss” vsteeeyr,pilc in hte gn)lu esrvsu susgeoa rai( in eht )unlg e.idam

    • d. resWeihpd puyioqtlerco si a clanclii etst yitcapyll rdpmrefeo nigdru a demacil ylasihpc tonaiixamen ot eavaleut fro het epsercen bgnnuflpso;& loi,nitnosdcoa ihhwc lcduo be uecads by naccre ld(ios )mssa or oiamnnuep dlf(ui ssm)a.

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? +  

 +3  upvote downvote
submitted by asharm10(15),

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

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.

 +1  upvote downvote
submitted by zevvyt(16),

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?

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.

 -19  upvote downvote
submitted by mattnatomy(41),
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lersaCkc eheitr eaticsdin crohnci obcitnsrhi or olaotioicndsn (mrof uenonmpai ro amyroupnl ame)d.e

vnGie htta 'ertehs yonl a 1 yda ohyirts of BSO, 'mI nnaelig erom oartwds lrabo nunm.ipeao eabMy a'tsht oasl twsah' ucnsiga the 3S at teh SL?LB If si't apSth eurusA, I essgu we lucod eb nlgokio ta ectua cedinirstoad + ?ianopmeun Or Q vereF? Btu att'sh stju .iulaecspotn duClo laos stju eb that eth ugnl nonaoidltosic si raintgel blodo fw,lo glndaei to teh bakc pu into eht ihtRg imrutA apm&; cVntiere.l

brise  Patient has CHF from the S3 heart sound and has MR. You hear fine crackles in early congestive heart failure. +14  
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. +