Mehlman trauma/pleural (10-29) (2)

Question 1

Pulmonary contusion. how to establish diagnosis on USMLE?

Answer 1

Difficult diagnosis.
Diagnosis of exclusion.

Question 2

Pulmonary contusion.
Q: accident + now has some form of difficulty breathing and patchy infiltrates in one or more areas of lung. They may or may not mention rib fractures just above the areas of infiltrates.

Answer 2

.

Question 3

Pulmonary contusion.
textbook description (apie xray)?

Answer 3

“white-out of the lung”

Question 4

Pulmonary contusion. sensitive to what?

Answer 4

Contused (bruised) lung is known to be fluid-sensitive.

Question 5

Pulmonary contusion.

Q can say patient was given IV saline and now has worsening of O2 sats -> Dx?

Answer 5

Pulmonary contusion.

This is classic, but I’ve also seen this in myocardial contusion questions, making the Dx difficult as I said.

But you’ll be able to eliminate myocardial contusion if they don’t mention severe bruising or pain over the sternum or post-MVA arrhythmia (e.g.,
premature atrial contractions).

Question 6

patient has paradoxical breathing (i.e., the chest wall moves outward with expiration and inward with inspiration). Dx?

Answer 6

Flail chest

Question 7

Flail chest, definition?

Answer 7

patient has paradoxical breathing (i.e., the chest wall moves outward with expiration and inward with inspiration).

Question 8

Ruptured bronchus, definition?

Answer 8

The answer on 2CK forms if they say there’s a “persistent air leak despite
placement of a chest tube.” This will be in a trauma patient.

Question 9

“persistent air leak despite
placement of a chest tube.” This will be in a trauma patient.

Answer 9

Ruptured bronchus

Question 10

Diaphragmatic rupture. definition?

Answer 10

The answer on 2CK forms for an MVA followed by CXR showing “obscured left
hemidiaphragm and the NG tube present in the lower left side of the chest.”

Question 11

MVA followed by CXR showing “obscured left hemidiaphragm and the NG tube present in the lower left side of the chest.” Dx?

Answer 11

Diaphragmatic rupture

Question 12

Dont confuse with what two pathologies that also can occur after trauma?

Answer 12

Don’t confuse with ruptured bronchus above, or with esophageal rupture, which
will tell you water-soluble contrast swallow is visualized in the mediastinum

Question 13

Pleural effusion. definition?

Answer 13

Fluid in the pleural space; often refers to “hydrothorax,” which means transudate or exudate of plasma-like fluid.

Question 14

Pleural effusion. USMLE wants what CP findings?

Answer 14

dullness to percussion,
decr. breath sounds,
decr. tactile fremitus.

both decr. because fluid in the overlying pleural space masks air movement in the alveoli.

Question 15

Pleural effusion. many causes on usmle.

what notable?

Answer 15

I’ve observed left heart failure as a notable cause (i.e., patient will have pulmonary edema +/- pleural effusion).

NBME can also give you pleural effusion with pneumonias, tuberculosis, and aortic dissection.

Question 16

Pleural effusion. Meigs syndrome, what is it?

Answer 16

triad of ovarian fibroma, ascites, right-sided pleural effusion.

Question 17

Pleural effusion.

triad of ovarian fibroma, ascites, right-sided pleural effusion.?

Answer 17

Meigs syndrome

Question 18

Pleural effusion.
USMLE wants you to know transudative versus exudative pleural effusions. how they look like?

Answer 18

transudates are more water-like, with fewer solutes; exudates contain more
solutes.

Question 19

Pleural effusion.
Light criteria (HY!!!), exudate:
Pleural fluid protein : serum protein ratio?

Answer 19

Pleural fluid protein : serum protein ratio >0.5.

Question 20

Pleural effusion.
Light criteria (HY!!!), exudate:
Pleural fluid LDH : serum LDH ratio?

Answer 20

Pleural fluid LDH : serum LDH ratio > 0.6.

Question 21

Pleural effusion.
Light criteria (HY!!!), exudate.

In other words, transudate contains less protein and LDH as the two main distinctions

Answer 21

.

Question 22

Pleural effusion.
Light criteria (HY!!!), exudate:

Pleural fluid LDH ……… of normal of serum LDH.

Answer 22

Pleural fluid LDH >2/3 upper limit of normal of serum LDH.

Question 23

Pleural effusion.

Transudates contain fewer WBCs than exudates, but I routinely see 500 WBCs/µL in transudate Q on NBME.

Answer 23

.

Question 24

Pleural effusion.
Highest yield cause of transudate on USMLE?

Answer 24

left heart failure

Question 25

Pleural effusion.
HY cause exudative pleural effusions (due to inflammation)?

Answer 25

ARDS, pulmonary emboli, and infections

Question 26

Pleural effusion. progress to what?

Answer 26

Progression to empyema HY (see below).

Question 27

Empyema. 2 ways on usmle.

Answer 27

.

Question 28

Empyema.
4/5 Q. Will be sequence: pneumonia -> parapneumonic effusions (exudative effusions that occur due to pneumonia) -> empyema.
pH of empyema? HY

Answer 28

<7,1

Question 29

Empyema.
1/5 Q. will not mention Hx of pneumonia.
Case: patient with persistent fever + recurrent pleural effusions due to cirrhosis (decr. oncotic p. -> transudative pleural effusions). Dx?

Answer 29

Empyema.

Question 30

Empyema. Tx?

Answer 30

nbme wants THORACOSTOMY to drain the purulence.

Question 31

Chylothorax. definition?

Answer 31

Chyle (lymph fluid) in pleural space.

Question 32

Chylothorax.

Q. Milky/white-cloudy fluid in the pleural space WHERE pH is significantly higher than 7,1.

Answer 32

.

Question 33

Chylothorax. pH?

Answer 33

significantly higher than 7,1.

Question 34

Chylothorax.

they might give you 15-line paragraph where they say milky fluid + tons of lab values, but you notice the pH of the pleural fluid is 7.40. This means it’s chylothorax and empyema is wrong.

Answer 34

.

Question 35

Chylothorax. causes?

Answer 35

Can be caused iatrogenically by insertion of central line via the left internal jugular vein, or by cancers, e.g., lymphoma

Question 36

Hemothorax. definition?

Answer 36

Blood in the pleural space.

Question 37

Hemothorax. apart from massive trauma, what in other case in usmle can occur?

Answer 37

The way this shows up on USMLE is as malignant pleural effusion

Question 38

Hemothorax.

They’ll give you massive paragraph with tons of info + tell you patient has history of breast or lung cancer + has dullness to percussion = answer?

Answer 38

malignant pleural effusion

Question 39

Hemothorax. CP simmilar to what?

Answer 39

Patient can have hypotension and muffled heart sounds, similar to cardiac tamponade, but rather than JVD (to complete Beck triad), can have flattened neck veins (due to loss blood from the circulation).