Case-based MCQ

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Correct Answer Is E A dry central perforation will not progress to complications, even if it does not heal. Surgical repair is, therefore, elective and not mandatory.The other types of perforation are not ‘safe’ and require specialist attention. A continuously discharging central perforation indicates granulation and a risk of osteitis and bone destruction.Marginal perforation carries the same risk. A cholesteatoma is not a neoplasm but a cystic lesion containing amorphous debris (and sometimes spicules of cholesterol). It is formed through chronic infection and perforation of the eardrum with ingrowth of squamous epithelium, forming a nest which becomes cystic. By progressive enlargement, a cholesteatoma can erode the ossicles, labyrinth and adjacent bone and carries the risk of cerebral abscess formation and meningitis

A 14-year old teenager is diagnosed with a tympanic membrane perforation secondary to chronic otitis media.Which of the following conditions will not progress to significant complications if left untreated? A. Perforation associated with a cholesteatoma B. Marginal perforation with discharge C. Continuously discharging central perforation D. Perforation that is surrounded by granulation tissue E. Large dry central perforation

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✔ 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.