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NBME 22 Answers

nbme22/Block 3/Question#38 (58.2 difficulty score)
A 73-year-old man comes to the physician with ...
Blood pressure🔍,📺
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 +6 
submitted by madeforupvoting2(13),
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APCP ciaenress narupatlerli epsurser as teh detleeva yaraiw rruspese si masntitedrt ot ehtor sgnhti in teh cayvti ug(nl eshpsu no eaurllp eaavpy/iccts chwhi nca neth push no hreot ttrueu.r)ssc Thsi acn dela to srmnsocoiep fo s,veni gnliudnic eth neva cvaa g;t-& reeaecdds vsouen rtnure &-;tg sdeecadre bp mf(ro dersaecde dp.ar)loe hiTs si samiril to htwa apespnh dnuigr lsvavlaa it(oerxen sp)aseh tguhoh eth ioteisvp esrusper is didverop yb a maechni mpup atsiend of ombailnda .u/csmrdagsapiehlm I hnikt htaer tera kellyi essenraic tdaensi fo cradesee as a noarepomytcs ere.possn

sr’eHe noe tise ttah pnlxeasi it wlel e(ht “fr”ee ectnotn is eoghnu nda aylrbbpo aeyldra edsecex eth hdetp neo mghit eden ot k)won thcteeuai.tvh-sna-poilrcnficrtefyontraotnmaxec:smoefm/a-//-clikhlc/etpayo

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. +9  

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(76),


 +5 
submitted by drpatinoire(13),
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yuGs I vhea hoetrna tg.uohht

vGiign ohetr cohiesc ear abtuo sih oreth alnmaorb uslaev saci(rdene eirectn,a oegcul,s urci cd),ai I suegs the useintoq si gntties su cwhhi of stehe suaevl lwil pireomv fi sih AOS si rpdomiev by .CPAP

ceiSn OAS is neo fo eth osmt mtnairtop ucasse fo ctiphidaio onipeteynrh,s ti hlsduo meoc ot su taht oecn ihs SOA is e,ratedt hsi pthneryeonis lwil meprovi osno.

oS ereddc"esa "PB nidtsae of oehrt blnroaam .usaelv

Tnk(sha ot my dfnrsei orf nnhtigi me uabto !h)tsi

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  



 +4 
submitted by meningitis(544),
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tAholhug si’t about PP,V shit esehragcnri dhleep em tdnudrenas abics sy,hp I hpoe hsti phsel eoeyvnre in osme w.ay

aTwakaey: Dnriug ,PPV nvuseo rrneut serdce,sae racidca utptou eeea,dscrs and herat esurprsse dsecerea ni eth thirg dsei of het hea.tr

hyW eosd PVP eraeescd osunve nuer?tr

  • hartriontaicc uresrpse eopsscersm ,tearh gscnuai bodlo nto to etrunr

asseCu orf raedsedce ltef lrrticeuvna uutotp dunrgi :tivanenoitl

  • hintSgif of rltientiuancrvra utpesm to Left ued to endesaicr VR omulev
  • eesDeacrd snuevo urenrt
  • Cgshane in estrah ibyitla to ocatctrn ude to sitvopei eseuprsr
  • clka fo 2O ot tearh

oamrlN pyrcootseanm nmahscesmi rfo niagtnanimi CO nad PB dgiunr PV?P

  • eniresdca HR to ceapontsem orf ecsrdedea VS
  • nrseeicad SRV to tmninaai PB

hOrte giosyiocPhl :rnssspeeo

  • eDcasdeer ebrlaerc fronspiue sepsruer ysdbo(’ enpresos to a afll in PCP si ot rsiae tcseysmi boold epursrse dna iledat lrearecb oolbd )seslves
  • cereaseDd alner sefrouinp arInsced(e H,DA ,AARS dan iettaPn has aenrl serlmobp os isednecra itranecien adn ruci dica)
  • ebsolisP nnrltumtoaii en(darscie couesgl avi lncnegsosoieegu .etc)
meningitis  sorry about the formatting, they were supposed to be bullets not italic. +28  
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  



 +3 
submitted by trump2020(6),

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

teepot123  yep +  



 +2 
submitted by cathartic_medstu(28),
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aCn emosneo rteorcc ym ongasnier hree:

I asw kntiihng oeipistv iayarw spsrreue wlli neesirca loarlvae itlvienaton dan asceeerd hyxiapo ndduice mnaopyurl iicnrnosottcvaos. ,ushT RV freta ldao wodul cereaesd t;g&= orme ardpleo ot VL dan more cracaid .totupu Tnhe tdn'lwou PB d?secaere

Any leph si ppei.edrctaa k.Tsanh

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  



 +1 
submitted by noselex(5),
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I ndentsurda spele eaanp wuodl ueasc hoxypai dan cenaeirs ni SSN cv.ititya oS ntmrtteae uowld ceuerd BP and eHatr ateR. I aws kstcu eeebntw teh otw sniotpo. hyW was eht sernaw olbdo sseurrep dna otn RH? I olggoed roanud a itb and uodfn idstseu taht swho rdpo ni hobt RH dna BP. I ssueg BP pords rmeo? Cna meoosne aleeps enl.apxi

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) https://thoracickey.com/extrapulmonary-effects-of-mechanical-ventilation/ +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. +  



 -4 
submitted by welpdedelp(227),
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asedInerc rcitiaaanlnr psserrue htat steusrl in ns'suhCgi artid of cseareind doblo srr,seeup rlegiuarr ,iehgrbtan adn .bcrardaaydi Thsu, hghi CO2 csudnei sugicnh airtd adn if you gevi PP thne ti illw crdeedu ,2CO nda ethn wndo ulereagt het siamtptcyeh ioc.ootansvnisrtc lirilnOayg eht anrbi adh so mchu C2O hatt it zapdezs out dna deitr to cerianse eht PB ni rdoer ot suhp orme geyndaotxe dlobo to hte ir.bna

kggc5:spZUaq/mmp.itASdlraA3ibjwCtJs/K.:/.teeoms/h-pfg

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