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NBME 22 Answers

nbme22/Block 4/Question#31

A 65-year-old man comes to the emergency department ...

Crackles

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 +2  upvote downvote
submitted by usmleuser007(84),

Just note why other answers are not correct:

  1. Egophony is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis.

    • a. It is due to enhanced transmission of high-frequency sound across fluid, such as in abnormal lung tissue, with lower frequencies filtered out.
  2. Whispered pectoriloquy refers to an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields on a patient’s torso.

    • a. Usually spoken sounds of a whispered volume by the patient would not be heard by the clinician auscultating a lung field with a stethoscope.

    • b. However, in areas of the lung where there is lung consolidation, these whispered spoken sounds by the patient (such as saying ‘ninety-nine’) will be clearly heard through the stethoscope.

    • c. This increase in sound exists because sound travels faster and thus with lower loss of intensity through liquid or solid (“fluid mass” or “solid mass,” respectively, in the lung) versus gaseous (air in the lung) media.

    • d. Whispered pectoriloquy is a clinical test typically performed during a medical physical examination to evaluate for the presence of lung consolidation, which could be caused by cancer (solid mass) or pneumonia (fluid mass).


 -7  upvote downvote
submitted by mattnatomy(20),

Crackles either indicates chronic bronchitis or consolidation (from pneumonia or pulmonary edema).

Given that there's only a 1 day history of SOB, I'm leaning more towards lobar pneumonia. Maybe that's also what's causing the S3 at the LLSB? If it's Staph Aureus, I guess we could be looking at acute endocarditis + pneumonia? Or Q Fever? But that's just speculation. Could also just be that the lung consolidation is altering blood flow, leading to the back up into the Right Atrium & Ventricle.

brise  Patient has CHF from the S3 heart sound and has MR. You hear fine crackles in early congestive heart failure. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518345/ +9  
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 +