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NBME 18 Answers

nbme18/Block 2/Question#28 (reveal difficulty score)
A 68-year-old man comes to the physician ...
Cor pulmonale 🔍 / 📺 / 🌳 / 📖

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 +11  upvote downvote
submitted by drdoom(1202)
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gnepiRsodn to @bizds’ria cetnmom:

kialcnfgilB fo oodlb form eht lnsgu inot eht R lvertcien si thicresgnt otu eht R edis o(l)aiintd nad laos mreodiegln hte rathe vai pephorrhtyy hte( taehr sha to pcka on mass ot tjece hte rvee tgreaer tuomna of dloob nilgip up mofr )n.sugl otDlnaii fo eth R cevrlient “lupls artp”a eht vleesa of teh icruptsid ea=lvvoewlr ltfe esrtlna edrbor; ehwn the trhea si ni eltssyo, eth idcputisr vlsvea dtn’o kame odog ttncaoc and ooldb ushers fmor ghhi sprreseu ontrmcptaem VR)( to eht owl pssrereu )RA( == apinolcstys mumrru

hTe rpsicudit urummr stge ewrso wiht osriiinptan sbeceau wehn oyu ksa senmoeo to ktea a ,good dpee ebtarh, eth gdmrihhpaa a( vyer rntsgo emcsul, n)edeid pllsu hte tirnee ahitorcc acge dwno nda utwaord (nonasepix) — nuinlcgdi eht terha! cuseaeB eth trahe ge“st lplued from all eoiisn”trdc, eht sutpicird flseelat eakm evne ssle cctnaot == ggeirb eloh == omer npnordueoc rmmruu indrug elso.sty

The nopit of ailxmam uslmpie t(he athre )pxea is awy leobw hte doiixph euesbca hits g’syu raeht si so gib mrof het asyre of oantildi dan oehpyhyrtrp — s’htta asol wyh 2S sudons era tanitsd: eht atreg evsesls n(ad reiht )lavevs rea ridbeu enev edeper thna sluau, os oyu ntc’a raeh mthe nnpasigp usth rac(toi am&;p uploncmi ;velavs bu”d)2=S.“

ahetr dsnou eaasr g&;t= pa:9gom./9s1gsdvoaeUp2otFte.lg/wpish.2pSp/L

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 +4  upvote downvote
submitted by thisshouldbefree(51)
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2 ckap gic rof 05 arsey = 010 cpka semdey ae TrNHa LE = FLH ehetyaoal gpml = RnHwoF ofr het trimnopta nigidnf; rrumm"u ttah raenssiec on praniti"nsio g-t&; shti si anicdiveit of hgrti dieds

cro elaumnlop = my feiionitnd is FH sa a elsutr fo a glnu deisesa

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 +2  upvote downvote
submitted by medstudent123425(2)
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eniGv sih orithys of gbien a cocirnh eoksmr ish ulngs rae eedsms pu he(t eheewsz atth are rdaeh dink of pntoi to ti ),too pblaoyrb anegild to purlynamo Tgnl/NuH .mboesplr And htta cna aeld ot tigrh esddi arteh lrafieu ihcwh acn esprten whti a cisprtidu gurnritgteiao which si teh ip-onstlsayc uurrmm ttah ete'rhy ktngial au.tbo athT gnlao hwit eth pgititn eamed nda teh yeegltaopamh daair(cc crirhs)ios kdin fo ntpoi uyo in het ercnitdio of ocr

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 +1  upvote downvote
submitted by azibird(278)
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Cna oseonem napexli het laphciys nnif?dgis

icCr"aad iaanomtxnei ohwss a reagd 6/2 aonlspsitcy urrumm dehar etsb at het rlweo ftle etalrsn ,edrorb ihwhc eeracnis no nirat.isionp Teh otpin fo iaxmmal simeplu is alatedpp in hte dish-bxiupo a Sare1 nad 2S nusdos rae dntsat"i

I 'tnod nnstdaderu woh yan fo thees duolw pseroocdnr ot roc olmu.enpal

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drdoom  Backfilling of blood from the lungs into the R ventricle is stretching out the R side (dilation) and also remodeling the heart via hypertrophy (the heart has to pack on mass to eject the ever greater amount of blood piling up from lungs). Dilation of the R ventricle “pulls apart” the leaves of the tricuspid valve=``lower left sternal border``; when the heart is in systole, the tricuspid valves don’t make good contact and blood rushes from high pressure compartment (RV) to the low pressure (RA) == ``pansystolic murmur`` +1
drdoom  The tricuspid murmur gets worse with inspiration because when you ask someone to take a good, deep breath, the diaphragm (a very strong muscle, indeed) pulls the entire thoracic cage down and out (expansion) — including the heart! Because the heart “gets pulled from all directions”, the tricuspid leaflets make even less contact == bigger hole == more pronounced murmur during systole. +4
drdoom  The point of maximal impulse (the heart apex) is way below the xiphoid because this guy’s heart is so big from the years of dilation and hypertrophy — that’s also why the S2 sounds are distant: the great vessels (and their valves) are buried even deeper than usual, so you can’t hear them snapping shut (aortic & pulmonic valves; S2=“dub”). +1
cancelstep  Similar to what's been said, but here's how I answered: Agree that a pancystolic murmur at LL Sternal Border is tricuspid regurgitation, increases with inspiration because increased right ventricle preload would increase amount of regurgitation. PMI in sub-xiphoid area means that the strongest contraction is happening sub-xiphoid which has to be due to right ventricular hypertrophy (left ventricular hypertrophy would push PMI towards axilla). Diffuse, scattered wheezes bilaterally are probably indicative of COPD from history of smoking which would cause a secondary pulmonary hypertension due to hypoxemia and vasoconstriction in the lungs (primary is idiopathic, most commonly occurs in younger/middle-aged females). So this explains why you have RVH. Pulmonary edema would be crackles on lung auscultation and would point to Left HF, but not the case here. Also, BP 150/80 in a 68-year old without any medication is definitely high, but not causing AS. Peripheral/liver edema = RHF +6

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