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NBME 19 Answers

nbme19/Block 4/Question#17 (reveal difficulty score)
60 yo man, 20-year history of hypertension; ...
Cardiac output: decreased; CVP: increased πŸ” / πŸ“Ί / 🌳

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submitted by βˆ—strugglebus(177),
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It alos oloedk ctelxay klie oemohstsics on teh litdes--i dah teh eilltt nis.ep enbtaomEa douwl vahe had a bcunh of sCRB

submitted by metformality(14),
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ishT aepnitt iwth a isyhrot hconicr ptseiynrenoh is most yiklle nugefifrs ofmr ftel aehrt rulaefi aese(dcder arcaidc u)outto,p uigcasn eth odolb to kcab pu ni the slnug lcas(erCk era daerh ,lytllriabea stnhsesor fo )ebhtra adn ahtt seluigrnt noit saeniderc ofaltdaer rof eth htgir deis of hte ehtra, iirnasg eth seruespr ni the ighrt ahrte e,arhmbsc cihwh get adsntrtemti ckab ot lcrtane vien.

anjum  shortness of breath = Left heart failure +3  
cassdawg  The way I approached the question was a little different: I realized it was heart failure and left would cause lung backup and right the venous backup. When addressing the +6  
cassdawg  *the question my thinking was CO = HRxSV; in heart failure we are not pumping as much blood so lower SV (and on top of that his HR is not increased and I think the low blood pressure indicates decompensated heart failure) so CO is definitely lowered. Then CVP would have to be increased because that is how we get the edema (and backup into the venous system increases CVP). +1  
chaosawaits  @cassdawg, I approached it very similarly. The best immediate indicator that this is cardiogenic shock is the pulse pressure (30 mmHg). Normal PP = 40-60 mmHg. Therefore, you know that CO has been compromised. The edema indicates that CVP (measurement of the venae cavae BP)has increased. +  
an1  because this guy has crackles and ankle edema, we know that there is LHF AND RHF respectively. the most common cause of RHF is actually LHF. So crackles mean that fluid is accumulating in the lung. Where will it back up? RV and RA causing increased CVP. Crackles mean LHF, and the the LV isn't working well, the cardiac output will decrease for sure +  

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