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NBME 24 Answers

nbme24/Block 4/Question#40 (48.1 difficulty score)
A 25-year-old woman is brought to the ...
Pulmonary capillary leakage🔍

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submitted by neonem(544),
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Tish pttiena tins' itpheyonvatgl,ni ye'erht PvHnaE,iegtilRtnY echen eht C2PO &;lt 04 mm H.g

Lst'e aklw it c:rksdabwa eyTh rae lhpegatvnietriyn ot nmeotaspec for eth oeiamclbt caissoid ueacds yb awseedrpdi axpo.ihy tevnlityrgHapein laowls uyo ot bolw off emor OC2.

yhW aer htye hicyx?po The esonpr si yopxchi due to aitlimafonnm dan atuce raeoprsityr teisdssr ndyesorm rfom the .neamiponu lAl eht kitcesnoy frmo teh tmrfylaamoin csell aceus sieneracd mrynlopau layaircpl ,alkegea ichwh lkobsc pu the vaorella mbremane so tath 2O a'ntc tge rhuhgto ot the o.obld

Why od yeth veah mboliteac oscisiad ni het tsrfi ?lpeca oN ongyxe g;-&-t no elrncote aontprtsr nchai and no TCA -&-t;g clitca

diabetes  no pneumonia it is UTI +3  
makinallkindzofgainz  The infection from the UTI spread to her lungs +  
makinallkindzofgainz  this is essentially urosepsis, one of the leading causes of sepsis +1  
cmun777  UTI -> Sepsis -> ARDS (exudative pathophysiology d/t increased pulmonary vasc permeability) +11  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +1  
thisshouldbefree  she has an increased A-a gradient. +  

submitted by dbg(139),
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iDd nnayeo slee nreodw WHAT O"UAPRMLYN "PTMSYSMO si eth neqotsui eferrnrgi to?? erheT si lytilalre ont a sgilen tyommps neinotdme ni teh owehl igvteent. oN srceal"ck eadhr rvoe othb unlg esf"ldi rea nto mop.ymsts hTey era issgn dnofu by teh hsanyi.pic

Sliuesyor togbduni hte loewh NMEB barod tste irtwsre higtr nwo. oD yhet teyqelaadu ersevi herti ?kowr ihsT si ton teh fsrti nclhtiace keatmsi I ereazil on eth enw f.rsmo

nbmehelp  Yup. Looking back its clear what they were trying to get at, but this definitely threw me off when I was taking the test bc I kept rereading the question looking for a specific symptom the pt had that they wanted me to explain. +2  
ergogenic22  I agree with you that the writers are whack but this question clearly says "diffuse crackles are heard over both lung fields" +2  
ergogenic22  i take that back i understand what you're saying +4  
peqmd  I think what are causing her pulmonary "signs" might be more accurate question. +1  

submitted by diabetes(25),
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UI)Ut( tg;&== isssep =E=;NCRADE&tS=g;gSI&R=tA lvaorlae ipraclyla teilmypebrai g&=;t= xpmheiaoy ;&=gt= ettiorpynniehval htpn=&pci=;agoya

avocadotoast  This is correct. The patient doesn't have pneumonia, but sepsis from her UTI. Sepsis is a known cause of ARDS. ARDS can be due to extra-pulmonary tissue damage that leads to the release of inflammatory mediators, alveolar damage, pulmonary edema, and hyaline membrane formation. The hyaline membranes impair gas exchange and lead to hypoxia. +1  

submitted by famylife(86),
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Frmo :PAAF

cte"uA yrriepsraot dirssste norsmyed si a msattnoainefi fo ucate niruyj ot teh ul,gn oconlmym unertglsi frmo ei,spss atrau,m adn eeersv mrnyulpao ifoinecst.n l,iCanycill it si ahreacetzrdic by ysae,dnp dpuonorf y,iomxapeh eecadrdse gnlu ec,oanmclpi dna ufsdefi birelalat rseitlifnat on etshc pa.rrid.oa.gyh

nI DAR,S het jeunird lgun is edlbevie ot go rtohuhg eethr ha:pses e,udaxvtei etaf,lvreiroip adn ,ortbific but teh cerosu fo heca aepsh dan het vorelal daieses irseongrspo is elbviraa. In hte ixvatuede hseap, gmaeda ot het veaorlla miulheiept nad uvrcaals eueitonhdlm crpseduo kgeelaa of e,tarw ipe,ntor adn onaymmfltari dna red lobod lslec iton the ntumiistetri and oelvraal um.eln Teesh ehsangc ear eddcniu yb a mceoxlp elpytnira of omnomryrapaflti dan rtnyalma-mnotiiaf eomtsai.r"d


submitted by sattanki(68),
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heT pt is hgvina a reesve scae fo ssipmoisenaun/pe ADS)R(?, sa ats’ht ywh reh 2OP si olw at .64 oS ni nanoupime teehr is eaeincdrs yrlpcaali gakaeel gadlien ot yrpnlmaou .edaem

submitted by ankistruggles(13),
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Hwo do uoy wnok erh nlmparyuo pmysmots rae ued ot pnumayolr rapalcyil elgakea adn ont ?avoletiohtynpni Is lnurmpyao aiarclpyl akeegal stuj arnetho ayw fo yanisg plonmayru deaem?

sattanki  Hypoventilation in no way leads to pulmonary edema. +  
fenestrated  Hypoventilation would increased the PCO2 +  

submitted by am4140(0),

I see people are having problem with the “pulmonary symptom” part, but they way I thought about it is: what symptom?

She’s tachypneic because the CO2 is low, which I’m sure she could have noticed before she passed out. Everything else is a sign. So what makes a patient tachypneic? Well, your lungs filling up with crap can do it, which it says in the question since she has diffuse bilateral infiltrates.

So what causes your lungs to have infiltrates? Well, she has a kidney infection that’s turned into septic shock with gram negative bacteremia, so it’s going to be all the inflammatory mediators we produce in response to all of that bacterial LPS in the bloodstream causing pulmonary capillary leakage and ARDS.