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NBME 22 Answers

nbme22/Block 4/Question#31 (31.6 difficulty score)
A 65-year-old man comes to the emergency ...
Crackles🔍
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 +9 
submitted by usmleuser007(370),
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tJsu oetn ywh rhote snerswa are not oe:rtccr

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    • d. sWiepedrh rcpyeoloiutq si a lclcniai etst yatlclpiy fropdreem dirung a delcmia pyahsilc ominantxaei ot vualeaet rof eht crenpees &fobnpl;gsnu otscolinda,ino whhic cloud eb uecdsa by cranec dsoil( )amss ro epianunom f(iuld )a.sms

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? +  



 +4 
submitted by asharm10(22),

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




 +2 
submitted by taediggity(30),

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! +  



 +1 
submitted by zevvyt(25),

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?




 +1 
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.




 -21 
submitted by mattnatomy(41),
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lseakCrc ethier eisdcaint croicnh rhtbocinis ro lnooicntoidsa ro(fm epmannuio or urmapnoly d.a)mee

ivneG thta htsere' ynlo a 1 ayd hroyits fo OS,B I'm ganlnie rmeo tdwoasr robla .oupnainme yMabe 'ahtst slao 'asthw gcusnia eht S3 ta teh SL?BL If tsi' htpSa ru,eAus I gsues ew luocd be koilngo ta uetac sddtoanireic + pn?onuimae Or Q v?ereF tuB ha'stt sutj uesnctoal.pi oldCu oals stju eb hatt teh ngul nanicostoliod is nlgeitra ooldb owlf, gealnid ot eth cakb up toin eth gtihR rAtmui ap;m& Vrineeltc.

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/ +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. +