frontal
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A 30-year-old paraplegic male has a long history of urinary tract infection secondary to an indwelling Foley catheter. He develops fever and hypotension requiring hospitalization, fluid therapy, and intravenous antibiotics. He improves, but over 1 week becomes increasingly short of breath and tachypneic. He develops frothy sputum, diffuse rales, and diffuse alveolar infiltrates. There is no fever, jugular venous distention, S3 gallop, or peripheral or sacral edema. The best approach to a definitive diagnosis in this patient is
A) Blood cultures
B) CT scan of the chest
C) Pulmonary capillary wedge pressure
D) Ventilation-perfusion scan
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| sobia naeem
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i would go for c..
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| achilles
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B- CT scan ??
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| amygdalaa
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Why not a VP scan? Is this PE?
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| achilles
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unlikely amygdalaa, there is no pain, no JVD and then frothy sputum is not a very likely symtom associated with PE...but i stand to be corrected,
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| amygdalaa
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achilles-frothy sputum is suggestive of pulmonary edema, right? So there must be LVF? So why not C?
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| mesh
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wat i think is that it could be due to either LVF or ARDS.............to differentiate b/w them, PCWP is the best thing to do............but likelyhood of ARDS is less here...because it occurs most commonly within 5 days of the event.......and no other clue is given regarding ARDS....
confused.....
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| achilles
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can you pls post the answer frontal.
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| PKG
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the diagnosis is ARDS. do a PCWP ....it will be normal.........as tis is non cardiogenic pulmonary edema
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| achilles
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amygdalaa, i thought you were referring to pulmonary embolism when you said PE(thats what we do a V/Q scan for) and thats why i said that its unlikely because there is no JVD, no chest pain and frothy sputum is not a symptom of pulmonary embolism...i surely agree that frothy sputum is a symptom of pulmonary edema.
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" it's not whether you get knocked down, it's whether you get up"
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| achilles
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PKG,mesh, i think you are right...looking back on the question i think i got this one wrong too...and i'll agree with C.
a swan-ganz cath. may be needed to exclude LVF as both can have a similar X-ray picture.
thanks guys for enlightening me.
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| frontal
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Sorry about the delay. Connection probs. Y'all have already arrived upon the answer and the explanation. It is C. (PCWP).
Here's an off-topic question: have most of you taken step 1 already? What about you achilles? I had decided on taking CK first, but now it seems 1 might be a better choice. Your thoughts?
Okay, I'm pasting the explanation:
The answer is c. Sepsis is the most important single cause of adult respiratory distress syndrome. Early in the course of ARDS, patients may appear stable without respiratory symptoms. Tachypnea, hypoxemia, and diffuse infiltrates gradually develop. It may be difficult to distinguish the process from cardiogenic pulmonary edema, especially in patients who have been given large quantities of fluid. This young patient with no evidence of volume overload would be strongly suspected of having ARDS. The pulmonary capillary wedge pressure would be normal or low in ARDS, but elevated in left ventricular failure. ARDS is a complication of sepsis, but blood cultures may or may not be positive. Neither CT of the chest nor ventilation-perfusion scan would be specific enough to help in diagnosis of ARDS.
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| achilles
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thanks for the answer frontal.
regarding your question, i am yet to take any usmle exam...i am giving my step 2 ck around end of may...i had been reading all these subjects for a while(i also gave my mccee which has the same course) and so i thought i'd better get over with step 2 ck first and then i'll go for step 1.
the way most people prefer to do it is give step 1 first and they all say that it does help to give step 1 first but how beneficial will that be i frankly dont know. i am giving my step 2 first because i have been reading these subjects for a while now. if you are just starting then i'll suggest start with step 1.
but dont give up on us...keep posting questions and keep visiting...we dont wanna lose you ...and these were all good questions...like i said i am learning a lot from you guys.
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| frontal
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That is my dilemma exactly. I had pretty much the same mindset as yours when I had vaguely decided on taking 2ck first. I've been doing the 2CK stuff for some months, though not too seriously, and as of now I do not think my performace would be satisfactory, were I to take a mock test. In any case, I'm more familiar with 2CK than with the step 1 content. But people say Step 1 gives you a good base. I'll make my decision soon.
Thanks once again achilles for those praises and good luck to you always.
-frontal.
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