doyoudig
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Now, please tell me the answer of this question  both questions are matching questions of NBME 2 block 4
A) Acute gastrointestinal bleeding
B) Adrenal insufficiency
C) Aortic valve rupture
D) Cardiac tamponade
E) Congestive heart failure
F) Pneumonia
G) Pulmonary embolism
H) Sepsis
8. A previously healthy 62-year-old man is broughtto the emergency department by paramedics 40 minutes after the suddenonset of severe shortness of breath while dressing this morning. He is unable to provide
additional medical history. He is in severe respiratory distress. His temperature is 37.8 C (100 F), blood pressure is 90/60 mm Hg, pulse is 120/min and regular, and respirations are 24/min. Examination shows marked jugular venous distention. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced and discrete point of maximal impulse and normal S1 and S2; there is an S4 and a right parasternal heave. Abdominal examination shows no abnormalities. There is no edema of the lower extremities. Laboratory studies show:
Hematocrit 40%
Leukocyte count 14,000/mm3
Platelet count 350,000/mm3
Arterial blood gas analysis on 5 L/min of oxygen:
pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg
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| doyoudig
Forum Guru
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Posts: 613
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I am adding the other NMBE question that was being disscussed, below for comparision, thx to all for great discussion. These 2 are impt questions u will likley encounter in the real exam.
A previously healthy 67-year-old woman is brought to
the emergency
department by paramedics 40 minutes after the sudden
onset of shortness of
breath while shopping. She is unable to provide
additional medical
history. She is in severe respiratory distress. Her
temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is
120/min and regular,
and respirations are 24/min. Examination shows marked
jugular venous
distention. Diffuse crackles are heard throughout all
lung fields.
Cardiac examination shows an enlarged point of maximal
impulse and normal
S1 and S2; there is an S3. Abdominal examination
shows no
abnormalities. There is no edema of the lower
extremities. Laboratory studies
show:
Hematocrit 38%
Leukocyte count 12,000/mm3
Platelet count 350,000/mm3
Arterial blood gas analysis on 5 L/min of oxygen:
pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg
A
) Acute gastrointestinal bleeding
B
) Adrenal insufficiency
C
) Aortic valve rupture
D
) Cardiac tamponade
E
) Congestive heart failure
F
) Pneumonia
G
) Pulmonary embolism
H
) Sepsis
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| doyoudig
Forum Guru
Topics: 144
Posts: 613
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pls compare these 2 questions.
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| Justice
Forum Fanatic
Topics: 106
Posts: 2,140
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1. G) Pulmonary embolism
2. D) Cardiac tamponade
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| doyoudig
Forum Guru
Topics: 144
Posts: 613
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agree on 1
but justice I thought Cardiac Tamponade would present w/ Clear Lung Fields?
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| khorshid
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Posts: 591
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I agree with justice , first one is embolism, second tamponade
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| khorshid
Forum Guru
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Posts: 591
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Sorry I correct myself the second one is CHF. you're right doyoudig except in mycoplasma cases tamponade is not with crackles. Patient has S3, increased JVP, dyspnea and displacement of PMI which all can be seen in CHF.( peripheral edema is not a necessaity I think). Correct me if I am wrong.
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| young_doc
Forum Guru
Topics: 55
Posts: 732
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I appreciate you extending the thread doyoudig... i can see that you won't give up until you convince everyone that the answer CHF! 
Unfortunely none of us will know with all certainty the correct answer to this puzzling NBME question.
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| Justice
Forum Fanatic
Topics: 106
Posts: 2,140
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Well, there is a limited number of events that could cause acute and sudden CHF, like papillary muscle tear and acute mitral valve prolapse... Can a self-standing CHF be that sudden? To me, tamponade may cause crackles via worsening diastolic function of left ventricle... But to favor CHF, I would like to know PCWP...
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| wywywy2006
Forum Elite
Topics: 43
Posts: 166
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Hi, Ir's a great discussion.
Have you pay attention to the situations which the two events occur ? For an elderly person, one occurs after sleep overnight (means immobilization over night) while the other occurs during shopping (means exertion). Do you fell excited and tired after walking in the mall for some time ?.
PE is for the event after sleep overnight; MI is the answer to the second one.
Please read Kaplan note internal medicine Page 121 about the presentation of MI: May be clinically silent, especially in postoperative patients, elderly patients............ It may present as CHF or dysrrhythmia in the absence of chest pain.
In the second case, its MI but clear present as CHF due to "elderly" patient.
I read all the discussion. I can't agree that this board exam will give atypical signs. All signs should be very typical but the principal behind the sign is the true thing they test and we should know.
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