Red flags

Red flags US Medical PG Question 1: A 51-year-old woman is brought into the emergency department following a motor vehicle accident. She is unconscious and was intubated in the field. Past medical history is unknown. Upon arrival, she is hypotensive and tachycardic. Her temperature is 37.2°C (99.1°F), the pulse is 110/min, the respiratory rate is 22/min, and the blood pressure is 85/60 mm Hg. There is no evidence of head trauma, she withdraws to pain and her pupils are 2mm and reactive to light. Her heart has a regular rhythm without any murmurs or rubs and her lungs are clear to auscultation. Her abdomen is firm and distended with decreased bowel sounds. Her extremities are cool and clammy with weak, thready pulses. There is no peripheral edema. Of the following, what is the likely cause of her presentation?

• A. Septic shock
• B. Neurogenic shock
• C. Obstructive shock
• D. Hypovolemic shock (Correct Answer)
• E. Cardiogenic shock

Red flags Explanation: ***Hypovolemic shock*** - The patient's presentation with ***hypotension*** (BP 85/60 mm Hg), ***tachycardia*** (pulse 110/min), ***cool and clammy extremities***, ***weak peripheral pulses***, and a ***firm, distended abdomen*** after a motor vehicle accident strongly suggests internal hemorrhage leading to hypovolemic shock. - The ***firm and distended abdomen*** is a key indicator of potential intra-abdominal bleeding, significantly contributing to the loss of intravascular volume. *Septic shock* - Septic shock is characterized by signs of infection along with organ dysfunction and circulatory compromise, often presenting with **fever** or **hypothermia**, and sometimes **warm extremities** initially due to vasodilation. This patient's temperature is normal, and extremities are cool. - While hypotension and tachycardia are present, the absence of clear signs of infection and the presence of a firm, distended abdomen make hypovolemia a more immediate concern following trauma. *Neurogenic shock* - Neurogenic shock typically follows severe spinal cord injury above T6, leading to a loss of sympathetic tone. This results in **hypotension with bradycardia** and **warm, dry skin** due to widespread vasodilation. - This patient is tachycardic and has cool, clammy extremities, which contradicts the classic presentation of neurogenic shock. *Obstructive shock* - Obstructive shock occurs due to a physical obstruction to central circulation, such as **tension pneumothorax**, **cardiac tamponade**, or **pulmonary embolism**. - There is no mention of absent breath sounds, jugular venous distention, muffled heart sounds, or other specific signs pointing to an obstructive cause. Lungs are clear to auscultation and heart rhythm is regular. *Cardiogenic shock* - Cardiogenic shock results from primary cardiac dysfunction, often presenting with signs of **heart failure**, such as **pulmonary edema** (rales), **jugular venous distention**, gallop rhythms, or new murmurs. - The patient has clear lungs, a regular heart rhythm, and no murmurs, which makes primary cardiac dysfunction less likely as the immediate cause of shock in this trauma setting.

Red flags US Medical PG Question 2: A 40-year-old Caucasian male presents to the emergency room after being shot in the arm in a hunting accident. His shirt is soaked through with blood. He has a blood pressure of 65/40, a heart rate of 122, and his skin is pale, cool to the touch, and moist. This patient is most likely experiencing all of the following EXCEPT:

• A. Decreased sarcomere length in the myocardium
• B. Increased stroke volume (Correct Answer)
• C. Confusion and irritability
• D. Decreased preload
• E. Increased thromboxane A2

Red flags Explanation: ***Increased stroke volume*** - The patient is experiencing **hypovolemic shock** due to significant blood loss, meaning their **cardiac output** is severely compromised. - In shock, the heart attempts to compensate by increasing **heart rate**, but **stroke volume** is typically decreased due to reduced **preload**. *Decreased sarcomere length in the myocardium* - In situations of significant blood loss and **decreased preload**, there is less venous return to the heart, leading to reduced end-diastolic volume. - According to the **Frank-Starling law**, reduced end-diastolic volume results in shorter initial sarcomere length, which reduces the force of contraction and thus, **stroke volume**. *Confusion and irritability* - **Hypovolemic shock** leads to widespread **tissue hypoperfusion**, especially to vital organs like the brain. - Reduced cerebral blood flow results in impaired brain function, manifesting as **confusion, irritability**, and altered mental status. *Decreased preload* - Significant blood loss leads to a reduction in the **total circulating blood volume**. - This reduction directly decreases the venous return to the heart, thus lowering the **end-diastolic volume** and subsequently, the **preload**. *Increased thromboxane A2* - In response to **vascular injury and bleeding**, the body initiates hemostasis, a critical component of which is platelet aggregation. - **Thromboxane A2** is a potent vasoconstrictor and platelet aggregator released by activated platelets to form a **platelet plug** and help stop bleeding.

Red flags US Medical PG Question 3: A 27-year-old man is brought to the emergency department 45 minutes after being involved in a motor vehicle collision. He is agitated. He has pain in his upper right arm, which he is cradling in his left arm. His temperature is 36.7°C (98°F), pulse is 135/min, respirations are 25/min, and blood pressure is 145/90 mm Hg. His breathing is shallow. Pulse oximetry on 100% oxygen via a non-rebreather face mask shows an oxygen saturation of 83%. He is confused and oriented only to person. Examination shows multiple bruises on the right anterior thoracic wall. The pupils are equal and reactive to light. On inspiration, his right chest wall demonstrates paradoxical inward movement while his left chest wall is expanding. There is pain to palpation and crepitus over his right anterior ribs. The remainder of the examination shows no abnormalities. An x-ray of the chest is shown. Two large-bore IVs are placed. After fluid resuscitation and analgesia, which of the following is the most appropriate next step in management?

• A. Bedside thoracotomy
• B. Surgical fixation of right third to sixth ribs
• C. Intubation with positive pressure ventilation (Correct Answer)
• D. Placement of a chest tube
• E. CT scan of the chest

Red flags Explanation: ***Intubation with positive pressure ventilation*** - The patient presents with **flail chest** (paradoxical chest wall movement with pain and crepitus), respiratory distress (tachypnea, shallow breathing), and **hypoxemia** (SpO2 83% on 100% oxygen) despite initial fluid resuscitation and analgesia. These are clear indications for **endotracheal intubation** and mechanical ventilation to stabilize the chest wall, improve oxygenation, and reduce the work of breathing. - **Positive pressure ventilation** helps to internally splint the flail segment, enabling more effective gas exchange and preventing further atelectasis. *Bedside thoracotomy* - **Bedside thoracotomy** is typically reserved for patients in traumatic cardiac arrest who have witnessed signs of life on arrival or are in profound shock unresponsive to other resuscitative measures, making it inappropriate here. - This patient is **hemodynamically stable** (BP 145/90 mmHg) and does not show signs of massive hemorrhage or cardiac tamponade requiring immediate thoracotomy. *Surgical fixation of right third to sixth ribs* - **Surgical fixation of rib fractures** is a more definitive treatment for flail chest but is not an immediate life-saving intervention in the setting of acute respiratory failure and hypoxemia. - While it can be considered later to reduce pain and improve pulmonary mechanics, the priority is to stabilize the patient's respiratory status through **ventilation**. *Placement of a chest tube* - **Placement of a chest tube** is indicated for pneumothorax, hemothorax, or empyema. While a pneumothorax or hemothorax could be present given the trauma and rib fractures, the primary issue driving this patient's acute respiratory failure is the **flail chest leading to inadequate ventilation and oxygenation**. - There is no mention of diminished breath sounds or hyperresonance/dullness to percussion, which would suggest pneumothorax or hemothorax as the primary and immediate problem after initial resuscitation. *CT scan of the chest* - A **CT scan of the chest** is an important diagnostic tool to assess the extent of injuries, but it is not an immediate therapeutic intervention for a patient in acute respiratory failure and severe hypoxemia. - Delaying definitive airway management for a diagnostic test in an unstable patient is **inappropriate** and could worsen the patient's condition.

Red flags US Medical PG Question 4: A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?

• A. Discharge without activity restrictions
• B. Discharge and refrain from all physical activity for one week
• C. Observe for 6 hours in the ED and refrain from contact sports for one week (Correct Answer)
• D. Administer prophylactic levetiracetam and observe for 24 hours
• E. Administer prophylactic phenytoin and observe for 24 hours

Red flags Explanation: ***Observe for 6 hours in the ED and refrain from contact sports for one week*** - This patient experienced a brief period of **confusion, headache, dizziness**, and **nausea** immediately after a head injury, which are symptoms consistent with a **mild traumatic brain injury (mTBI)** or **concussion**. - Although his symptoms have resolved at presentation, observation in the ED for a few hours is prudent to ensure no delayed onset of more severe symptoms, and he should **refrain from contact sports** for at least one week as part of concussion management. *Discharge without activity restrictions* - Discharging without activity restrictions is unsafe given the initial symptoms of **confusion** and the potential for delayed symptom presentation or complications from a concussion. - Concussion management requires a period of **physical and cognitive rest** to allow the brain to heal and prevent **second impact syndrome**. *Discharge and refrain from all physical activity for one week* - While refraining from all physical activity for one week is part of concussion management, discharging immediately without any observation period after initial neurological symptoms could be risky. - An observation period allows for monitoring of any **worsening neurological signs** or symptoms that might indicate a more serious injury. *Administer prophylactic levetiracetam and observe for 24 hours* - **Prophylactic anticonvulsants** like levetiracetam are typically not recommended for routine management of **mild traumatic brain injury** or concussion. - Their use is generally reserved for patients with more severe injuries, evolving conditions, or those who have had **seizures post-trauma**. *Administer prophylactic phenytoin and observe for 24 hours* - Similar to levetiracetam, **phenytoin** is an anticonvulsant and its prophylactic use is not indicated for **mild head injuries** or concussions. - Anticonvulsant prophylaxis is associated with potential side effects and is reserved for specific high-risk scenarios, such as **severe TBI** or **penetrating head trauma**.

Red flags US Medical PG Question 5: A 6-month-old male presents to the emergency department with his parents after his three-year-old brother hit him on the arm with a toy truck. His parents are concerned that the minor trauma caused an unusual amount of bruising. The patient has otherwise been developing well and meeting all his milestones. His parents report that he sleeps throughout the night and has just started to experiment with solid food. The patient’s older brother is in good health, but the patient’s mother reports that some members of her family have an unknown blood disorder. On physical exam, the patient is agitated and difficult to soothe. He has 2-3 inches of ecchymoses and swelling on the lateral aspect of the left forearm. The patient has a neurological exam within normal limits and pale skin with blue irises. An ophthalmologic evaluation is deferred. Which of the following is the best initial step?

• A. Genetic testing
• B. Complete blood count and coagulation panel (Correct Answer)
• C. Ensure the child's safety and alert the police
• D. Peripheral blood smear
• E. Hemoglobin electrophoresis

Red flags Explanation: ***Complete blood count and coagulation panel*** - The unusual amount of **bruising** after minor trauma, along with a family history of an unknown blood disorder, strongly suggests a potential **bleeding disorder**. A **CBC** and a **coagulation panel** (PT, aPTT, fibrinogen) are essential initial steps to evaluate for abnormalities in platelets, clotting factors, or other hematologic conditions. - These tests can help narrow down the differential diagnosis between **platelet dysfunction**, **coagulopathies** (like hemophilia or von Willebrand disease), or other less common bleeding disorders, guiding further specific investigations. - **Important consideration:** The presence of **blue sclera** (described as "blue irises") raises concern for **osteogenesis imperfecta (OI)**, a connective tissue disorder causing bone fragility. However, initial hematologic screening is still appropriate given the family history of blood disorder and presentation of excessive bruising. If coagulation studies are normal, imaging and further workup for OI would be indicated. *Genetic testing* - While a genetic component is plausible given the patient's family history and clinical presentation (blue sclera may suggest osteogenesis imperfecta), **genetic testing** is typically performed *after* initial laboratory workup has identified a specific type of bleeding or inherited disorder. - Starting with genetic testing without basic hematologic parameters is not the most efficient or cost-effective initial diagnostic approach. *Ensure the child's safety and alert the police* - While child abuse should always be considered in cases of unexplained or excessive bruising, the presence of a **family history of a blood disorder** and the **blue sclera** (suggesting possible osteogenesis imperfecta) make **medical causes** more immediate concerns for initial investigation. - Pursuing a medical workup first often clarifies whether abuse is the primary explanation, although child protective services should be notified if suspicion remains high after medical evaluation. *Peripheral blood smear* - A **peripheral blood smear** provides information on red blood cell morphology, platelet size and number, and white blood cell differential. While useful in assessing for some hematologic conditions, it is often performed *after* a CBC has indicated abnormalities or in conjunction with specialized testing. - It would not be the *best initial step* as it doesn't directly assess clotting factor function, which is critical in evaluating significant bruising severity. *Hemoglobin electrophoresis* - **Hemoglobin electrophoresis** is used to diagnose **hemoglobinopathies** like sickle cell anemia or thalassemia. - The patient's symptoms (easy bruising) are not characteristic of hemoglobinopathies, and while he has pale skin, this test would not be the initial step to investigate a bleeding disorder.

Red flags Flashcard 1 of 5

Question: Varicocele is associated with left-sided _____ carcinoma

Answer: renal cell

Red flags Flashcard 2 of 5

Question: A retropharyngeal abscess commonly presents with fever, _____ pain, drooling, and cervical lymphadenopathy

Answer: neck

Red flags Flashcard 3 of 5

Question: What are the signs and symptoms of stage 2 Lyme disease?

Answer: bilateral facial nerve palsy, AV node block

Red flags Flashcard 4 of 5

Question: Paraesophageal hernias are associated with _____ in lung fields

Answer: bowel sounds

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Red flags Flashcard 5 of 5

Question: Spinal metastases present with back pain that is worse at _____, and is not relieved by position changes / analgesics

Answer: night

Extra Information:  https://onlinemeded.org?ref=anki