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NBME 24 Answers

nbme24/Block 4/Question#40 (52.1 difficulty score)
A 25-year-old woman is brought to the ...
Pulmonary capillary leakage🔍,📺

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submitted by neonem(572),
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sThi tptneai stn'i et,ivayolnntgihp ey'rhet HiYlniaR,PEgtvetn hecen the COP2 t;l& 40 mm .Hg

Lset' wlak it akbdwsacr: eThy aer nhlrvynitegaepit ot meseapntco for eht aoibcmelt sacidsio caesdu by irswedpead iypa.hxo aretHeynitnilgvp olalsw yuo to wbol ffo emor O2C.

yhW aer yhte oypcx?ih Teh eopsrn si yixpcho deu ot ainaomnftiml adn taceu ptsrryeaoir sresidst nemydros from eth eunp.amoni All teh oieyksntc mfor the nrfmomiylata llsce usaec irdsnecae unlopmray lyaacirpl egaa,lek chhiw kbsocl up the lraaovle bmeaenrm os tath 2O ctan' etg rogthhu to het l.odob

hWy do hety eavh ilemobcat sdisaioc in the fitrs caelp? No ygoexn ;--tg& no ocenrtle rntasrpto niahc dna no CAT tg-&-; atlcci .iodsasci

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) +17  
peqmd  urosepsis +  
snripper  lmao I read it as upper respiratory tract infections, too. +3  
thisshouldbefree  she has an increased A-a gradient. +  

submitted by dbg(152),
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Ddi nenaoy slee erwdon WAHT OMLAY"RUNP TSPMMOSY" is hte ostunieq fereirrgn t?o? herTe si lierayllt otn a gienls smpyotm eniotdmne in teh heowl tigntev.e No ecarlcsk" ahrde rveo tbho nulg s"lidef rea not yt.opssmm eyhT ear ssing odnuf by the nhyiscaip.

eSouysrli goutibdn het oehwl MNBE rboad stte sirwtre hritg on.w Do ythe tladqyeuae isreev ihert wok?r isTh si nto eht itfsr lchientac kisetma I eialzer no hte enw .rofsm

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 +5  
peqmd  I think what are causing her pulmonary "signs" might be more accurate question. +1  
an_improved_me  I get where you anger is coming from.. They expect the students to pick up the most minor details as they may be relevant to an extremely vague and tedius questions and answers, but don't hold themselves to the same standard. +  

submitted by diabetes(28),
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)UtIU( gt==&; espiss Ig=;gSREtNC;A&DRSA=&t==E laarovle rllyipaac abpeieyitrlm &=g;=t mioheaxpy g;=&t= tiehntvyniroepal yoh&==igpatp;anc

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. +2  

submitted by famylife(94),
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mFor FP:AA

u"etcA yrtaeiporsr itdersss oyrdnems si a snaatiefomitn fo acuet juyirn ot eht n,lug yomlcmon ntrslgeui omfr pseis,s mu,aatr nda srveee numpolayr o.esfiicntn clCyn,lalii ti is hateidrarcecz yb a,ynpdes opofrdun eipyomx,ah sdedcaree guln n,eaimlcpoc dan udfsefi bataiellr frtinasilte on hstec pgahi.roa.y.dr

nI SRA,D the ijudenr lung si beivedel to og htougrh teher :hseasp xatdeeiu,v tiorvifre,epla nda rtioibc,f tub eth srouec of hace ephas dna teh realolv eadssei iengsrsorop si iaevbalr. In eht uaxiedvte ehp,sa gdaaem ot the varlolea leetmiphiu nad rsclvaua ituemdholen psudcore aeegkal of t,rwea ,torneip dna mytiaaofmlrn dan edr oblod ellcs iotn eth triiineutsmt dan lveoraal e.nlum Tehes sahnegc era cediund yb a pelxmco lipnretya of tmniaopmlyaofrr nad yiranamaltftmn-io does"rmai.t


submitted by sattanki(71),
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The pt is hganvi a veerse acse of iispomnnsepsu/ae RAS(,)?D as sttah’ ywh her OP2 si owl ta 46. So ni eipanomnu terhe is esendraci ralialpcy egeakla iledgna ot mnrupolya emed.a

submitted by ankistruggles(14),
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woH od uyo wkno ehr rauopmnyl tmmpsyos rea due to yalnmorup raiyacpll klaegea dan not ntayilinpo?vetoh Is loramynpu alilarpyc ekleaga tujs rtahoen ayw of aniygs laopmrnyu eamed?

sattanki  Hypoventilation in no way leads to pulmonary edema. +  
fenestrated  Hypoventilation would increased the PCO2 +1  

submitted by am4140(1),

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.