Case-based MCQ

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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A 68-year-old nursing home resident man, with long standing chronic obstructive pulmonary disease (COPD), has been brought by ambulance to the emergency department because of an exacerbation of his condition. En route to the emergency depart m en t, he was severely short of breath and was given oxygen 10 L/min via nasal canula. On examination, he is drowsy and disoriented. Which one of the following could be the most likely result of his arterial blood gas (ABG?) A. Ph=7. 29, PaC0 2=65mm Hg, Pa0 2=85mm Hg B. Ph =7 .15, PaC0 2=50mm Hg, Pa0 2=68mm Hg C. Ph =7.25, PaC0 2=25mm Hg, Pa02=1OOmm Hg D. Ph =7.35, Pa C0 2= 40mm Hg, Pa0 2=40m m Hg E. Ph =7 .45, PaC02=85mm Hg, Pa0 2=40mm Hg

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Correct Answer Is A Chest X-ray shows loss of right heart border silhouette due to partial atelectasis of right middle lobe. Atelectasis is collapse or incomplete expansion of the lung or a part of the lung. Postoperative atelectasis generally occurs within 48 hours. It is an extremely common post-operative complication with some degree of pulmonary collapse occurring after almost every abdominal or trans-thoracic procedure. Postoperative atelactasis can be managed as follows: 1-Removal of impacted secretions by coughing, managed by physiotherapists, and involves active chest percussion and breathing exercises. 2-Passive postural drainage. All other options are incorrect

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A young woman underwent a non-complicated cholecystectomy for painful gallstones.After 24 hours of surgery, she developed a cough and fever.Chest X-ray is done as shown below. How would you manage? A. Chest physiotherapy B. Give morphine C. Give antibiotics D. Give steroids E. Paracetamol as required

Correct Answer Is A This patient’s clinical features are worrisome for iatrogenic septic bursitis, presenting with acute pain following an initial positive response to corticosteroid injection.  Subacromial injections are used to treat subacromial bursitis, rotator cuff tendinopathy, and adhesive capsulitis.  During the procedure, the needle penetrates the subacromial bursa, depositing corticosteroids into the bursa and near the supraspinatus tendon.  However, injection can introduce skin flora (eg, Staphylococcus aureus, Streptococcus pyogenes) into the deep structures. Infection typically manifests as worsening pain, redness, swelling, and systemic symptoms (eg, fever, myalgias) several days after the procedure.  In contrast, postcorticosteroid injection flare (ie, steroid-induced chemical synovitis) typically occurs rapidly and resolves within 48 hours.  In some cases, the bursa communicates with the glenohumeral joint capsule, and septic bursitis may progress to septic arthritis.  When infection is suspected, an image-guided (eg, ultrasound) aspiration of the bursa and/or joint is necessary to assess for infection. Range-of-motion exercises and analgesics are appropriate for adhesive capsulitis, which presents with pain and reduced shoulder motion in multiple axes.  However, adhesive capsulitis is a chronic condition that presents insidiously; this patient’s acute pain, swelling, and myalgias are more consistent with septic bursitis. Intraarticular and soft tissue corticosteroid injections are contraindicated when infection is suspected because they can worsen the infection.  In the absence of infection, repeat injections are typically separated by at least several months to reduce the risk of tendon rupture and cartilage damage. Gout can cause acute inflammatory bursitis resembling septic bursitis but likely would have responded completely to the initial corticosteroid injection.  Furthermore, the serum uric acid level, even when elevated, does not rule out infection and cannot replace a diagnostic aspiration. Shoulder x-ray is useful to assess for fracture (which is unlikely in the absence of trauma) but is not sufficient to rule out infection. During a joint or bursal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as worsening pain several days following the procedure.  Diagnostic aspiration of the joint or bursa is necessary to assess for infection.

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A 65-year-old man returns to the office for follow-up 10 days after receiving a subacromial corticosteroid injection for right-sided rotator cuff tendinopathy.  The tendinopathy was confirmed on musculoskeletal ultrasound of the shoulder prior to the injection.  The patient initially experienced mild improvement of the shoulder pain, but starting 2 days ago, the pain significantly worsened and is now accompanied by generalized body ache and fatigue.  He does not report trauma or excessive shoulder use since the injection.  Medical history includes type 2 diabetes mellitus and gout.  Temperature is 37.9 C, blood pressure is 130/85 mm Hg, and pulse is 109/min.  On examination, there is mild swelling in the lateral right shoulder.  Range of motion is limited in multiple axes due to significant pain, which is worse compared to examination prior to the injection.  Which of the following is the most appropriate next step in management of this patient? A. Image-guided aspiration B. Range-of-motion exercises and analgesic therapy C. Repeat corticosteroid injection D. Serum uric acid level E. X-ray of the shoulder