NBME Practice Shelf Flashcards
Post-operative pt has sudden onset dyspnea while receiving blood transfusion. Reports back pain & painful IV site. On exam, pt is diaphoretic, has a low grade fever, tachypneic, normo-tensive, saturates well on room air. Skin exam is negative, breath sounds are CTAB, & the incision site looks good. Diagnosis?
Acute hemolytic transfusion reaction
2/2 preformed Abs to transfused blood &
ABO incompatibility (clerical error)
Etiology & Management of
Acute Hemolytic Transfusion Reaction
ABO incompatibility / Pre-formed Abs
Stop transfusion immediately and provide supportive care
Acute hemolytic transfusion reaction results in profound hemolysis and presents with:
≥ 99ºF
back/flank pain
hemoglobinuria (dark pee),
A positive ___ test.
Rapidly progresses to→ ____
Coombs
DIC
Immune response to transfused ___ may be s/t:
1. Anaphylactic reaction to donor’s Ig
2. IgA deficient pts
3. Host Inflammatory response s/t excess cytokines in the donor’s plasma
(aka febrile nonhemolytic transfusion reaction)
plasma proteins
Donor plasma proteins
can illicit a host immune response in what 3 scenarios?
- Anaphylaxis
- _____ deficient pts
- _____ transfusion reaction
- IgA deficient
- Febrile non-hemolytic transfusion reaction
Acute hemolytic transfusion reactions
s/t transfused ___ incompatible RBCs
(Host/recipient) ___ attack
(Donor) ___ on the surface of RBCs
resulting in hemolysis & fever
ABO incompatible RBCs
Preformed antibodies (host)
ABO antigens (donor)
Pt presents with acute onset respiratory distress, crackles fever, and ± Hypotension within minutes to 6 hours after starting a transfusion
Dx & Tx?
Transfusion related acute lung injury (TRALI)
Treatment is supportive (ventilation, vasopressors, antipyretics)
*Donor WBCs (Anti-Leukocytes) Abs attack recipient
New infiltrates/pulm edema on CXR that develop within 6 hours of transfusion of any blood product
Transfusion related acute lung injury (TRALI)
or TACO
Patients who develops respiratory failure secondary to transfusion associated cardiac overload
TACO
Transfusion associated cardiac overload
Patients who recover from TRALI can receive blood products but these products should not be from the
same prior blood donor
Pt has shortness of breath immediately after beginning transfusion of blood products. T 100°F, Tachycardic, Tachypneic, normotensive, SO2 82%, crackles in bilateral lungs, cyanosis of extremities, & clear urine. Diagnosis?
Transfusion related acute lung injury (TRALI)
May present with tachycardia, hypoxia, and chest pain, but diffuse crackles on pulmonary examination would be unusual for a
PE
Pt presents with hypotension, tachycardia, AMS, and organ dysfunction in the setting of a presumed infection. General Dx?
Sepsis
(if unsure of dx consider temporal relationship of sxs as hinting at the more likely dx)
[Organ] is most commonly injured organ in the setting of blunt abdominal trauma injury. It can present with abdominal tenderness and (if severe) hemodynamic instability from large-volume hemo-peritoneum.
spleen
*exploratory laparotomy is the next best step in
HD–unstable pts
Pts with splenic injuries may have left upper quadrant tenderness, peritonitis or referred pain to the ___
Left shoulder
(s/t diaphragmatic irritation)
Hemodynamically stable patients with minor splenic injuries may be treated with ___
observation and reassessment
(Repeat CT scan in 24hrs)
Trauma patient is alert with neck pain, numbness and paresis below mid-chest. Pt has low grade fever, normal pulses, unlabored respiration, and BP 80/50. C-spine XR shows fractured C7/T1. BP does not improve after infusion of 2L IVFs, why?
Neurogenic shock s/t
Spinal Cord Injury.
*injury to autonomic (SNS) fibers from motor medulla center. Cannot get input from baroreceptors in the aortic and carotid sinus to regulate BP due to injured sympathetic fibers which cant signal vessels to vasoconstrict (lose vascular tone & dilate)
Neurogenic Shock occurs when a spinal cord injury causes injury to ____ fibers from motor medulla center. These fibers are no longer able to get input from ____ baroreceptors to regulate BP. Hence vessels can’t ___.
Additionally, injury to sympathetic fibers from the Cardiovascular Center in the medulla may also lead to ___.
autonomic (SNS)
aortic & carotid sinus
vasoconstrict (lose vascular tone & dilate)
bradycardia
Neurogenic Shock s/t spinal cord injury results in:
Hypotension (refractory to IVFs)
& Bradycardia (in SOME cases)
Management of this may include (3)
- Fluid resuscitation
(for maintaining perfusion) - Atropine– antimuscarinic block PSNS
(for bradycardia) - Vasoactive pressor– Nor-Epi/ADH
(to maintain MAP)
____ can lead to neurogenic shock through disruption of autonomic centers however patients present with altered mental status, not just neurologic deficits like in spinal cord injury
Closed head injury/ traumatic brain injury
Female presents with a 3 weeks history of headache; today headache has worsened with new blurred vision. Pt is obese afebrile with mild hypertension. Fundoscopy shows bilateral papilledema. Negative head CT.
Dx & next best step in management?
Idiopathic intracranial hypertension
Lumbar Puncture
*caused by inadequate resorption of cerebrospinal fluid and is characterized by signs of increased intracranial pressure like headache papilledema and elevated opening pressure on LP without gross abnormalities on Imaging
In Idiopathic intracranial hypertension, headaches may worsen when __ and relieved by ___.
lying down
standing
Medication’s associated with IIH include tetracyclines, growth hormones and danazol (for endometriosis/ fibrocystic breast)
If Idiopathic intracranial hypertension is suspected (Female, Fat, Migraines, Papilledema) what is the initial and second step in evaluation?
CT Head
if CT is normal, LP
Management of Idiopathic intracranial hypertension includes:
1. weight loss
2. [Med]
3. therapeutic [Procedure]
in rare cases
4. [surgical intervention]
- Carbonic anhydrase Inhibitors
- lumbar puncture
- CSF shunt
(or optic n. sheath fenestration)
IV administration of ___ is useful for the acute management of optic neuritis was generally presents with acute onset vision loss, ocular pain worsened by ocular movements, decrease visual acuity/color, and
pupillary defects.
(Most commonly associated with multiple sclerosis)
Methylprednisolone
Elderly male presents with lesion on his nose gradually increasing in size over the years. Lesion is a 1cm pinkish red dimple with rolled borders and central shiny, raw ulceration on the tip of nose. Diagnosis and next best step in management?
BCC
excision bx (5mm- 1cm) or Mohs procedure (if on face)
Complete surgical excision with a margin of between __ to __ is recommended as first-line treatment for BCC located in non-critical areas amenable to complete resection
5 mm – 10 mm
(0.5 cm – 1.0 cm)
*In critical areas of the face or other delicate regions pick:
Mohs micrographic surgery → visible lesion layer excised, viewed under microscope, another thin layer is excised and examined until no more cancer is seen
Management of mild frostbite include rewarming the affected area in warm water, analgesia, and admission to the hospital for ___
observation &
wound care
Immediate ___ in the affected extremities is indicated in pts with acute limb ischemia with LOSS of pulses
Arteriography
*If limb is threatened but has some doppler A/V flow or sensorimotor fxn → Arteriography → Heparin & Revascularization via:
Percutaneous balloon angioplasty
Stent
Thrombectomy or Bypass
*Irreversibly damaged necrotic limb w/o doppler flow & sensorimotor fxn → amputation
___ and stent placement are options for
revascularization in patients with PAD but the presence of gangrene is an indication for amputation
Percutaneous balloon angioplasty
POD #3 pt with cardiac hx presents with abdominal pain, anxiety, diaphoresis, and tachycardia. Next best step in management (2)
ECG and Troponin
If PE is considered, is a D-dimer or CTA better?
CTA
Patients with severe or symptomatic aortic stenosis (Syncope, Angina, Dyspnea)
decrease ___
or a LVEF less than __% benefit from aortic valve replacement which may be performed surgically or through a transcatheter approach
exercise tolerance
Less than 50%
Etiology of TACO
Transfusion causing fluid overload in patient with a h/o CHF or other cardiac hx
Etiology of TRALI
Donor’s blood contains antibodies to recipient’s leukocytes/WBCs
Name that Transfusion Reaction:
Wheezing, Angioedema, Dyspnea, (+Hypotension), s/t recipient IgA Abs → within minutes
Anaphylactic
Name that Transfusion Reaction:
Red wheels s/t Host IgE Abs → within 2 hrs
Febrile Non-Hemolytic: Fever, chills, Dyspnea, Clear lungs, Clear urine → within 6 hrs
Urticarial
Transfusion Reaction that presents with:
Fever,
± hypotension,
Dyspnea,
Clear lungs,
Flank (or back) pain,
Dark urine
→ within 1 hr
Acute Hemolytic
Transfusion Reaction that Presents with:
Respiratory distress
(pulmonary infiltrates/Crackles/edema)
± hypotension
within 6 hours after transfusion initiation
TX: immediate transfusion cessation and respiratory supportive care
TRALI
(Supportive = vent/pressors/antipyretic)
Name that Transfusion Reaction:
Afebrile, Dyspnea, Crackles in lungs, HTN → within 6 hrs of transfusion
Resolves with Diuresis
TACO
