Case-based MCQ

✔ E Pressure in the left renal vein may become elevated due to compression where the vein crosses the aorta beneath the superior mesenteric artery.  This "nutcracker effect" can cause hematuria and flank pain.  Pressure can also be elevated in the left gonadal vein, leading to formation of a varicocele

An 18-year-old man comes to the clinic due to hematuria and intermittent left flank pain of several months duration.  He has no history of trauma or sexually transmitted diseases and no associated fever or dysuria.  Examination reveals a soft abdomen with normal bowel sounds and no localized tenderness.  Urinalysis confirms 3+ blood but no white blood cells, crystals, or organisms.  Contrast-enhanced CT scan shows no abnormalities in the ureters or kidneys but does reveal compression of the left renal vein between the superior mesenteric artery and the aorta.  Which of the following is most likely to develop due to the vascular abnormality seen in this patient? A. Esophageal varices B. Left-sided ankle swelling C. Periumbilical venous distension D. Rectal varices E. Varicocele

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Correct Answer Is B This patient has a diaphragmatic rupture with herniation of abdominal contents into the thoracic cavity.  Diaphragmatic rupture can occur after blunt thoracoabdominal trauma (eg, motor vehicle collision) due to a sudden and unequal increase in thoracoabdominal pressure, resulting in tears or avulsion.  The left diaphragm is more prone to injury than the right due to congenital weakness in the diaphragm’s left posterolateral region and the liver’s protective effects on the right side.  Some patients (especially children) with traumatic diaphragmatic injury may initially have no symptoms and can present months to years later after progressive expansion of the diaphragmatic defect. Due to the mass effect of the abdominal organs in the thorax, symptoms may be related to lung compression (eg, chest discomfort, dyspnea), and chest x-ray may show bowel loops within the thoracic cavity and mediastinal shift.  Delayed diagnosis is also associated with increased risk of hernia formation and bowel strangulation, which can be fatal.  Although this patient’s x-ray findings suggest diaphragmatic injury, CT scan of the chest and abdomen is performed because it is more sensitive and is the definitive diagnostic modality.  Surgical repair is indicated after the diagnosis is confirmed, and CT scan aids in planning of operative approach (eg, thoracotomy vs laparotomy). Chest tube insertion is appropriate for patients with a large fluid collection such as hemothorax (which would appear as a homogenous consolidation) or pneumothorax (which would appear as a single air-filled pocket outside of the visceral pleural line).  This patient has multiple air-filled loops, suggestive of bowel. Flexible bronchoscopy visualizes the proximal airway lumen and mucosa to assess airway patency and continuity.  In the trauma setting, it may be used to diagnose tracheobronchial injury.  Although blunt trauma increases the risk of tracheobronchial injury, this patient has no respiratory distress or associated x-ray findings (eg, pneumomediastinum, pneumothorax, subcutaneous emphysema). Pneumonia is unlikely in the absence of fever and with a chest x-ray showing no infiltrates; therefore, intravenous antibiotics are not required. Diaphragmatic rupture should be suspected in patients with prior blunt thoracoabdominal trauma and abnormal chest x-ray findings (eg, bowel loops in the thorax, mediastinal shift).  Delayed presentations can occur after progressive expansion of the diaphragmatic defect and abdominal organ herniation.  CT scan of the chest and abdomen confirms the diagnosis.

A 4-year-old boy is brought to the emergency department with vague chest discomfort.  Two months ago, the patient was involved in a high-speed motor vehicle collision but sustained only minor injuries.  He was observed in the emergency department overnight and discharged home.  Medical history is otherwise unremarkable.  Vital signs are normal.  Auscultation of the lungs shows decreased air entry into the left lower base.  An x-ray of the chest is shown below. Which of the following is the best next step in management of this patient? A. Chest tube placement B. CT scan of the chest and abdomen C. Flexible bronchoscopy D. Intravenous antibiotics E. Reassurance and outpatient follow-up

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Explanation: Correct Answer Is D This patient’s presentation is consistent with acute pulmonary edema.  She was intubated for adequate oxygenation and further airway security.  The ideal location of the distal tip of the endotracheal tube (ETT) is 2-6 cm above the carina.  Because the right mainstem bronchus diverges from the trachea at a relatively non-acute angle, an ETT advanced too far will preferentially enter into the right main bronchus.  This results in overinflation of the right lung, underventilation of the left lung, and asymmetric chest expansion.  Auscultation will show markedly decreased or absent breath sounds.  Chest x-ray confirms the diagnosis.  Repositioning the ETT by pulling back slightly will move the tip between the carina and vocal cords and solve the problem. A left-sided chest tube may be used if the patient has a pneumothorax, hemothorax, empyema, or malignant effusion requiring drainage on that side.  Needle thoracostomy is usually performed as an emergency procedure in patients with a life-threatening tension pneumothorax.  Tension pneumothorax can occur after blunt chest trauma.  Although it can present similarly to this patient, there is usually significant hemodynamic compromise (eg, hypotension).  This patient’s markedly decreased breath sounds immediately after intubation makes malpositioned ETT more likely. Pericardiocentesis is performed in patients with cardiac tamponade or large symptomatic pericardial effusions.  Unlike in this patient, cardiac tamponade presents with hypotension, distended neck veins, pulsus paradoxus, and muffled heart sounds. This patient’s clinical presentation suggests right main bronchus intubation.  Increasing the tidal volume will increase the minute ventilation into her right lung and potentially worsen the ventilation perfusion mismatch.  As a result, tidal volume increases are contraindicated in this setting. Right mainstem bronchus intubation is a relatively common complication of endotracheal intubation.  It causes asymmetric chest expansion during inspiration and markedly decreased or absent breath sounds on the left side on auscultation.  Repositioning the endotracheal tube by pulling back slightly will move the tip between the carina and vocal cords and solve the problem.

A 67-year-old woman with a past medical history of hypertension, hypercholesterolemia, and type 2 diabetes calls 911 for severe dyspnea.  Her symptoms started 2 hours ago with chest pain and progressed rapidly to orthopnea and dyspnea.  Her blood pressure is 170/100 mm Hg and pulse is 120/min and regular.  A third heart sound is present.  Bilateral crackles are heard on chest auscultation.  Her oxygen saturation is 78% with 40% inspired oxygen.  She is intubated in the field by paramedics for progressive respiratory failure and treated with nitrates and diuretics.  After initial measures, breath sounds on the left side are markedly decreased.  Her repeat blood pressure is 168/96 mm Hg.  Which of the following is most likely to restore breath sounds to the left hemithorax? A. Left-sided chest tube B. Left-sided needle thoracostomy C. Pericardiocentesis D. Repositioning the endotracheal tube E. Tidal volume increase

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Explanation: Correct Answer Is B With the exception of traumatic rupture of aorta, all the given options have respiratory distress and hypoxia as a common and early presentation. Furthermore, equal pulses of both arms make traumatic rupture of the aorta a very remote possibility. With atelectasis and post-obstructive pneumonia, fever is expected to be present. This patient is afebrile making these two less likely. In hemothorax, chest exam is not normal, and the following are present: Mild to moderate shortness of breath (commonly) Absent breath sounds on the base of the affected side The base of the affected lung is dull to percussion Faint and distant breath sounds on the apex of the affected side With respiratory distress and hypoxia following blunt chest trauma 24-48 hours after the incident and a normal chest exam, pulmonary contusion would be the most likely diagnosis. Pulmonary contusion is the bruising of lung parenchyma due to trauma. It is most commonly caused by direct blunt trauma to the chest wall or in explosions or a shock wave associated with penetrating trauma. The condition may not show up immediately after the injury and may become evident 1 or 2 days after the trauma. This necessiates close monitoring of every patient with considerable trauma to the chest wall. Hypoxia and respiratory distress are main manifestations. Pulmonary contusion is very difficult to diagnose only based on chest exam, as exam findings are almost always inconclusive. Chest X-ray is the initial diagnostic tool; however, chest X-ray often underestimates the size of contusion and tends to lag behind the clinical picture. Affected areas show up as whitening of the affected area. In one-third of the patients. radiological characteristics may take an average 6 hours to develop. The true extent of injury takes 24-48 hours to develop. When the radiologic appearance is evident in a short time aft er the incidence, a CT scan must be performed for assessment of associated injuries. Pulmonary contusions usually resolve in 3 to 5 days, provided no secondary insult occurs. The main complications of pulmonary contusion are ARDS and pneumonia. Approximately 50% of patients with pulmonary contusion develop acute respiratory distress syndrome (ARDS). This percentage increases to 80% if more than 20% of the lung is affected. Direct lung trauma, alveolar hypoxia, and blood in the alveolar space are all major activators of an inflammatory pathways resulting in acute lung injury. Pneumonia is also a common complication of pulmonary contusion. Blood in alveolar spaces provides an excellent growth medium for bacteria. Clearance of secretions is decreased with pulmonary contusion,and this is augmented by any chest wall injury and mechanical ventilation. Good tracheal toilet and pulmonary care is essential to minimize the incidence of pneumonia in this susceptible group

A 42-year-old woman sustained a motor vehicle accident (MVA) 2 days ago and was brought to the emergency department by ambulance.She was resuscitated accordingly, and was admitted to the hospital due to ribs and her left humerus. Today, she is found to be in respiratory distress. Pulse oxymetry shows oxygen saturation of 89% on room air. On examination, she has a blood pressure of 130/88mmHg, pulse rate of 100bpm in both arms, respiratory rate of 30 breaths per minute, and a temperature of 36.7°C. Lungs and heart are clear on auscultation. Supplemental oxygen by facial mask is started and a chest X-ray obtained that shows whitening of the left pleural angle. Which one of the following is the most likely diagnosis? A. Traumatic rupture of aorta B. Pulmonary contusion C. Pneumonia D. Hemothorax E. Atelectasis

Correct Answer Is A The clinical picture is consistent with carbon dioxide (Co2) narcosis. Agitation, confusion, tremors, convulsions, and possible coma may occur if blood levels of carbon dioxide rise to 70 mmHg or  higher. Individuals with chronic obstructive pulmonary disease(COPD) can have CO2 narcosis with no symptoms other than confusion and/or drowsiness, because they have already developed tolerance to elevated amounts of CO2. When ventilation is sufficient to maintain a normal Pa02 in the arteries, the carbon dioxide partial pressure is generally expected to be near 40 mm Hg. This patient has been on high-flow oxygen so his blood oxygen content is expected to be normal or even  high. On the other hand, this patient is dependent on hypoxia rather than hypercapnia as the main stimulant of respiratory drive.With excessive oxygenation respiration will be suppressed and he is likely to have CO2 retention and increased blood CO2. CO2 retention also results in respiratory acidosis

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