3 Rakesh Flashcards
- After a diffi cult intubation on a 65-year-old with cervical spondylosis,
the patient presents with paralysis of upper limbs but only weakness of
the lower limbs. Cervical spine X-ray shows only degenerative changes.
What is the diagnosis?
A. Central cord syndrome.
B. Brown–Sequard syndrome.
C. Posterior cord syndrome.
D. Anterior cord syndrome.
E. Transverse myelitis.
D
- Answer: A
Hyperextension of the spine in patients with degenerative spine changes, particularly in the elderly,
is associated with central cord syndrome.
The clinical features are due to selective damage to the
central portion of the anterior cord, which carries the corticospinal tract and decussating fi bres of the
lateral spinothalamic tract
There is greater weakness of the upper limbs compared to the lower limbs.
This is because the motor fi bres of upper limbs in the corticospinal tract are nearer to the centre. In
Brown–Séquard syndrome there is ipsilateral loss of vibration and proprioception along with ipsilateral
spastic paresis. In posterior spinal cord syndrome there is bilateral loss of proprioception and vibratory
sensation. Bilateral spastic paresis below the level of lesion is seen in anterior spinal cord syndrome.
- An adult male who was an unrestrained driver in an accident is rushed to the hospital.
He has multiple bruises over anterior chest and abdominal wall.
His blood pressure is 70/30 mmHg and his pulse rate is 100/min.
Trachea is midline.
Pulmonary capillary wedge pressure (PCWP) is 12
mmHg. After rapid administration of 1 L crystalloid, the PCWP is 22 and BP is 75/30 mmHg with pulse rate 123/min. The likely diagnosis is:
A. Myocardial contusion. B. Pulmonary embolism. C. Pneumothorax. D. Hypovolaemic shock. E. Neurogenic shock.
D++2. Answer: A
Hypotension and tachycardia following trauma is consistent with shock. The most common cause
of shock in these settings is hypovolaemia. The PCWP is low in hypovolaemia.
Following a fl uid challenge the PCWP increased with no corresponding change in blood pressure.
These fi ndings exclude the diagnosis of shock caused by hypovolaemia. Elevated CVP/PCWP with
persistent hypotension after fl uid bolus should suggest an alternative diagnosis. The clinical fi ndings
are not suggestive of pneumothoax in this patient. Pulmonary embolism is associated with high
pulmonary artery pressure but normal PCWP. Myocardial contusion should be suspected in this
patient, which can be confi rmed with elevated cardiac enzymes and ECG changes.
- A 46-year-old heavy smoker has decreased breath sounds at the right lung base on the second day following upper abdominal surgery.
He is afebrile and his vital signs are stable, but he is hypoxaemic.
Chest X-ray shows a triangular opacity in the right lower chest. The most eff ective
strategy to prevent this condition is:
A. Broad-spectrum antibiotics given preoperatively.
B. Broad-spectrum antibiotics given postoperatively.
C. Smoking cessation 1 week before surgery.
D. Preoperative use of glucocorticoids.
E. Active breathing exercises.
E
- Answer: E
This patient has developed postoperative atelectasis. Obstructive atelectasis occurs due to airway
blockage, resulting in air retention distal to the occlusion.
This affected lobe or segment collapses
when the retained air is absorbed.
Postoperative atelectasis usually sets in within 48 h of the procedure. The patient presents with hypoxaemia and respiratory alkalosis, as these patients usually
hyperventilate to compensate for the drop in P aO 2 .
This condition can be prevented by initiating early
chest physiotherapy and active breathing exercises.
Use of broad-spectrum antibiotics or routine use
of glucocorticoids is not useful for preventive respiratory complications in this setting. Patients should stop smoking at least 8–10 weeks prior to surgery to reduce the risk of pulmonary complications.
This should be done carefully to prevent any complication associated with sudden cessation of smoking.
- A 45-year-old patient on warfarin for atrial fibrillation presents with acute abdomen. X-ray shows gas under the diaphragm. His blood results show haemoglobin of 9.2, platelet count of 90 000/mm 3, and INR of 2.1.
Which of the following is the best initial treatment preoperatively?
A. Fresh frozen plasma. B. Vitamin K. C. Packed RBC transfusion. D. Desmopressin. E. Platelet transfusion.
A
- Answer: A
This patient has perforation of bowel and requires an emergency laparotomy. His INR of 2.1 must be
corrected prior to the surgery. This warfarin-induced abnormal prothrombin time can be normalized
by infusion of fresh frozen plasma (FFP), which restores vitamin-K-dependent clotting factors. This
patient might require RBC transfusion later, but correction of the coagulation profi le is a priority.
FFP is obtained from whole blood and contains all the clotting factors. It lasts for 12 months. It is
also a source of cholinesterase. The activity of labile clotting factor is maintained, as FFP is stored
at − 30 ° C. Immediately before use it is thawed at 37 ° C.
- On day 3 following severe traumatic brain injury, an adult patient still has raised intracranial pressure (ICP), despite adequate sedation, elevation of head end, and removal of CSF. How can hyperventilation
decrease ICP in this patient?
A. By decreasing capillary leak. B. By increasing PO 2 . C. By causing cerebral vasoconstriction. D. Increased venous outflow from head. E. By causing cerebral vasodilatation.
C
- Answer: C
Brain parenchyma, CSF, and blood determine ICP, which is a function of volume and compliance.
Brain parenchyma and CSF volume is usually constant unless there is a mass lesion or obstruction to
CSF flow. The brain autoregulates cerebral blood flow and cerebral perfusion pressure. In traumatic
brain injury autoregulation may be hampered. Cerebral blood fl ow increases with hypercapnia and
it is important to maintain P aCO 2 at the lower end of normal values in patients with brain injury.
Elevation of head end decreases ICP by increasing venous outfl ow.
Adequate sedation in these
patients is essential in order to decrease metabolic demands and control blood pressure. Mannitol
may be used to extract free water out of brain tissue. Hyperventilation washes out CO 2 leading to
cerebral vasoconstriction. Current guidelines encourage normocapnoea.
- A 1-day-old term neonate is transferred to your regional paediatric ICU.
A congenital diaphragmatic hernia has been diagnosed. The baby is already intubated and receiving artificial ventilation.
Which of the following is incorrect about this condition?
A. Stomach should be deflated using oro-gastric tube to reduce lung compression.
B. Early enteral nutrition should be commenced.
C. Adequate sedation usually obviates need for paralysis.
D. Allow (permissive) hypercapnia, as aggressive ventilatory support may damage the
vulnerable lungs.
E. Surgery will improve lung function and oxygenation.
A
- Answer: E
Congenital diaphragmatic hernia (CDH) is a congenital anomaly consisting of a defect in the
diaphragm. It is also known as a Bochdalek hernia. The incidence is between about 1 in 2000 and
one in 3000 newborns. It is usually associated with pulmonary hypoplasia (PH) and persistent
pulmonary hypertension (PPH).
Newborns with CDH have high rates of mortality and morbidity,
which is attributed to severe respiratory failure secondary to PH and PPH. Initial treatment includes
achieving adequate peripheral and central venous access for drugs.
Ideally, monitoring should
include CVP, IABP, EtCO 2, pre- and postductal S pO 2, core and peripheral temperatures, and hourly
urine output.
The stomach should be defl ated using an orogastric tube, which reduces lung compression. Enteral
nutrition should be commenced early. Adequate sedation with fentanyl or midazolam usually
obviates need for paralysis.
While ventilating these patients, minimize mean airway pressures and allow (permissive)
hypercapnia, as aggressive ventilatory support damages the vulnerable lungs.
High-frequency
ventilation may help reduce shear forces and volutrauma in these children. Inhaled NO may be of
short-term benefi t in selected patients with severe pulmonary hypertension (PHT). ECMO has only
marginal eff ects on long-term survival. About 30 % of aff ected babies receive ECMO in the USA.
Use of surfactant has shown no benefi ts in term babies.
Surgery should be delayed until the patient
is stable, with no PHT crises and when ECMO and/or NO have been discontinued.
Surgery will not
improve oxygenation/lung function.
- A previously fi t 24-year-old patient has been admitted to your intensive
care unit with an isolated severe head injury. Eighteen hours after
admission he develops polyuria. Which of the following is not a feature
of central diabetes insipidus?
A. Urine osmolality less than 200 mOsmol/kg.
B. Urinary sodium concentration 20–60 mmol/L.
C. Plasma osmolality less than 280 mOsmol/kg.
D. Serum sodium concentration greater than 145 mmol/L.
E. Urinary specifi c gravity less than 1.005.
c
- Answer: C
The diff erential diagnosis of this condition includes central diabetes insipidus, drug-induction
(diuretic therapy, use of hypertonic saline, ingested alcohol), and cerebral salt-wasting syndrome.
Central diabetes insipidus
There is a disproportionate loss of water over sodium:
z urine osmolality < 200 mOsmol/kg
z urinary Na concentration 20–60 mmol/L (normal)
z plasma osmolality > 305 mOsmol/kg
z serum Na concentration > 145 mmol/L
z urinary specifi c gravity < 1.005.
- One day after admission for traumatic fracture of femur a young man
is found to have petechial rash, and he is confused and tachypneic. ABG
shows pH 7.49, PO 2 6.7, and PCO 2 3.7. The most probable diagnosis is:
A. Haematoma of the thorax.
B. Pulmonary embolism.
C. Fat embolism.
D. Staphylococcus aureus pneumonia.
E. Pulmonary oedema.
c
- Answer: C
Hypoxia, confusion, and petechial rash following fracture of femur are suggestive of pulmonary
embolism. This is caused when fat enters the venous circulation after fracture of long bones. Usually
this presents between 12 and 36 h following the trauma.
Pulmonary embolism has a longer latent
period and does not cause petechial rash.
Fat embolism is caused by dispersion of fat droplets into the circulation. This occurs after trauma
or surgery involving major bones.
It is also associated with major burns, acute pancreatitis, cardiopulmonary bypass, and transplantation of bone marrow.
Clinical features include confusion and restlessness. Patients may present with reduced
consciousness or seizures. Respiratory manifestations include dyspnoea, cough, and haemoptysis.
‘Snowstorm’ appearance on X-ray is characteristic of this condition. It is common to fi nd reduced
platelet count in these patients.
Management includes oxygen therapy and respiratory support.
- A COPD patient presents with aching in both wrists, clubbing, and weight loss. The skin is warm and red. X-ray of wrists shows periosteal thickening and possible infection. Which of the following is the most
appropriate treatment?
A. Perform chest radiograph. B. Aspirate wrist joint. C. Treat the patient with methotrexate. D. Obtain ESR. E. Treat with antibiotics.
E
- Answer: A
The clinical picture is suggestive of hypertrophic pulmonary osteopathy (HPO), which is
characterized by clubbing, arthritis, and periosteal new bone formation. Conditions that may
present with HPO include malignancy, lung abscess, congenital heart disease, etc. Bilateral
osteomyelitis of wrist is very unlikely. Periosteal new bone formation and clubbing is not a feature
of rheumatoid arthritis. Therefore, methotrexate or wrist aspiration is not the right choice of
treatment.
Chest X-ray should be performed to look for signs of infection of malignancy. Antibiotic
treatment is not empirically recommended. HPO without clubbing may go unrecognized.
Vascular endothelial growth factor, platelet-derived growth factor, and platelets are involved in the
pathogenesis of this condition. HPO may present without clubbing and about 20 % of cases have
hypertrophic osteoarthropathy without detectable malignancy.
- A 68-year-old patient with congestive heart failure is to receive total hip replacement. Which of the following is the best prophylaxis to prevent pulmonary embolism, if the patient has no other significant medical history?
A. Early mobilization.
B. Clopidogrel 75 mg/day.
C. Aspirin 325 mg/day.
D. Warfarin (to maintain INR between 2 and 3) or low molecular weight heparin (LMWH).
E. Subcutaneous heparin 5000 units every 12 h.
A
- Answer: D
Pulmonary embolism (PE) results from introduction of blood clots, air, foreign material, etc. into
the venous system. Clots from the lower limbs (usually above the knee) and pelvis are usually
responsible.
They can also originate from right side of the heart. Pulmonary embolism increases dead
space and vascular resistance. There is loss of surfactant, and within 48 h the affected segment can
become atelectatic.
Embolus in a large pulmonary vessel can result in infarction. In the event that
the patient survives acute PE the thrombus resolution usually begins within 2 weeks.
In patients with a high risk of developing PE, warfarin is recommended for prophylaxis. It should
be started preoperatively to maintain INR between 2 and 3. Low-molecular-weight heparin
given subcutaneously twice daily is also an option. Pneumatic boots, elastic stockings, and early
ambulation also reduce the risk of PE but are not adequate in high-risk patients. In this setting
warfarin is more eff ective than low-dose subcutaneous heparin.
- A 54-year-old patient admitted to the intensive care unit has low-grade fever.
On examination of chest, he has decreased excursion on right side and reduced fremitus. The percussion note is dull and breath sounds are decreased on right side. The trachea is deviated to left. The most likely
diagnosis is:
A. Pneumonic consolidation. B. Atelectasis. C. Chronic obstructive pulmonary disease. D. Pleural eff usion. E. Pneumothorax.
D
- Answer: D
The clinical fi ndings are suggestive of right side pleural eff usion. A large pleural eff usion can push the
trachea to the opposite side.
Atelectasis on the right side pulls the trachea to the right side. This occurs secondary to volume loss on
the aff ected side. When the lower lobe is aff ected by atelectasis, the diaphragm is elevated on that side.
In consolidated pneumonia there will be increased tactile vocal fremitus and no tracheal deviation.
COPD will not cause tracheal deviation by itself and the signs are bilateral.
- An alcoholic patient with poor oral hygiene presents with cough and
fever. Chest X-ray reveals air-fl uid level in the superior segment of right
lower lobe. The most likely causative organism is:
A. Mycoplasma pneumoniae.
B. Anaerobic agents.
C. Legionella.
D. Haemophillus infl uenza .
E. Streptococcus pneumoniae.
E
- Answer: B
The air-fl uid level is suggestive of pulmonary abscess, which is characteristic of infection by
anaerobes.
Pulmonary abscess is characterized by necrosis of lung tissue, resulting in formation
of cavities. Primary lung abscess is usually caused by aspiration of oral anaerobic bacteria into the
lungs. Other mechanisms of lung abscess include septic emboli to the lung, usually originating from
the heart valves and septic thrombophlebitis.
Patients usually have a history of loss of consciousness. Infection in the superior segment of the
right lower lobe suggests aspiration. Anaerobic infections cause a necrotizing process in the lungs.
Streptococcus pneumonia can cause cavitations but it is rare.
- A 65-year-old patient with pulmonary oedema is intubated and ventilated. Echocardiogram shows ejection fraction of 44 % , with severe mitral regurgitation (MR). There is no improvement even
after aggressive treatment with furosemide. What is the next best step in treating this patient?
A. Start the patient cautiously on a second-loop diuretic.
B. Start the patient on enalapril.
C. Start the patient on β -blocker.
D. Patient will need placement of intra-aortic balloon pump (IABP).
E. Arrange for mitral valve replacement surgery.
- Answer: B
This patient has developed pulmonary oedema due to severe MR. His cardiac output is determined
by after-load and the resistance to fl ow across the abnormal mitral valve. A large fraction of stroke
volume will fl ow into the left atrium, which is the cause of pulmonary oedema in this patient.
Reducing afterload in this patient is necessary to reduce pulmonary oedema. ACE inhibitors,
nitroprusside, and hydralazine can be used to treat the cause of pulmonary oedema in this patient.
On the other hand, IABP will worsen the patient’s condition. β -blockers do not reduce afterload.
The patient will need to be optimized before mitral valve replacement surgery.
- A 19-year-old primiparous at 32 weeks presents with BP of 158/98 mmHg, 1 +proteinuria, and tonic clonic seizure. Which of the following is indicated in immediate treatment for this patient?
A. Antihypertensive therapy. B. Emergency caesarean section. C. Magnesium sulphate. D. Load the patient with phenytoin. E. Aspirin.
C
- Answer: C
Control and prevention of seizures is a priority in patients with eclampsia. This patient has
eclampsia and requires caesarean section. Magnesium sulphate (MgSO 4 ) is the treatment of choice
for preventing further seizures. A loading dose of MgSO 4 is administered, followed by continuous
infusion for prophylaxis. Randomized control trials have shown magnesium sulphate to be better
than diazepam or phenytoin in seizure prophylaxis.
Systolic pressure greater than 160 mm Hg and diastolic pressure more than 110 mmHg is an
indication for treatment with antihypertensive medication to prevent stroke. Hydralazine and
labetalol are commonly used.
Calcium and aspirin have been used to prevent preeclampsia.
Magnesium plays a important role in many cellular functions, and there is increasing interest in its
role in medicine. There is now clear evidence of magnesium’s benefi t to patients with eclampsia or
torsades de pointes arrhythmias. There is some suggestion that magnesium has antinociceptive and
anesthetic properties as well as neuroprotective eff ects.
- A 30-year-old with placenta praevia has a caesarean section under general anaesthesia. Which of the following is contraindicated in
this patient with uterine atony?
A. Intramuscular methylergometrine. B. Hemabate suppository. C. Misoprostol suppository. D. Intravenous terbutaline. E. Prostaglandin E2 suppository.
D
- Answer: D
Failure of the uterus to contract following delivery is the most common cause of postpartum
haemorrhage in obstetrics.
Uterine atony accounts for about 75 % of postpartum haemorrhage.
Oxytocin and ergot alkaloids represent the cornerstone of uterotonic therapy. Prostaglandin
therapy has been studied more recently as an attractive alternative.
Newer medical therapies aimed at achieving uterine tamponade include recombinant factor VII and
hemostatic agents, and adjunctive nonsurgical methods.
Terbutaline is a tocolytic agent and is contraindicated in uterine atony. All other agents can be used
in this patient to increase the uterine tone.
