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NBME 5 Question - step3_2013
32. A 72-year-old white woman with emphysema comes to the office because of a 2-week history of unsteadiness when she
rises from bed in the morning. She says she feelsgroggy for 10 to 15 seconds on standing, after which her sense of balance
improves; she has not fallen. She has not had visual symptoms, headache, or focal weakness. She uses a salmeterol
metered dose inhaler and takes no other medications. The patient is 165 cm (5 ft 5 in) tall and weighs 56 kg (123 lb); bMI
is 20 kg/m^2. Vital signs are temperature 36.6 C (97.8 F), pulse 88/min supine and 96/min standing, respirations 22/mi
and unlabored, and blood pressure 158/76 mm Hg supine and 122/60 mm Hg standing. Physical examination is
unchanged from previous visits. Neurologic examination shows no focal findings. The patient asks, “Do a lot of people my
age have this problem, or is it just me?” In determining the severity of the patient’s orthostatic blood pressure change in
copmparison with those of other patients her age, you refer to a recent study of orthostatic changes in blood pressure
measurements in outpatients older than 65 years of age. The data are shown.
Postural Blood Pressure Changes (Supine to Standing)
Mean Change in Pressure Standard Deviation of Change
Systolic blood pressure - 4 mm Hg 15 mm Hg
Diastolic blood pressure - 2 mm Hg 11 mm Hg
In the study, change in blood pressure is normally distributed. In explaining the severity of the patient’s orthostatic blood pressure
change in relation to that of the patient’s in this study, which of the following should the patient be told?
A. The degree of orthostatic is less than the average orthostatic change in people her age
B. The degree of orthostatic change of her blood pressure is right in line with what is expected in someone her age
C. The degree of orthostatic change in her diastolic blood pressure is relatively greater than the change in her systolic
D. The degree of orthostatic change in her systolic blood pressure is higher than that of 98% of patints her age
E. Orthostatic blood pressure changes as large as hers are common, occurring in approximately one in six people her age

Can someone explain why D is the right answer? Thanks in advance!
Because the patient systolic blood pressure changed from 158 to 122 which is 36 mm hg change with 15 mm cg being 1 SD means translate to about 2.4 SD that can fit in 36 mm hg which translate to about 98 percentile
That’s right
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