The Dark Side of Medicine Online Trivia | Miscellaneous Health

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1. Mrs. X, a known diabetic, cut her finger while cooking a week ago. The wound progressively got worse and now she has fever. Since having diabetes predisposes Mrs. X to bad outcomes from infection, she agrees with her doctor when he suggests hospitalization for intravenous antibiotics. Within minutes of administration of penicillin, Mrs. X has a severe reaction which includes hives and swelling of the tongue and lips. She becomes pale and anxious and starts wheezing. "I can't breathe, I'm going to die!" she yells and then she becomes unconscious. This severe form of allergic reaction is known as which of the following?

Answer: Anaphylaxis

An anaphylactic reaction is characterized by an acute onset of manifestations shortly after exposure to a noxious allergen. Features include hives, breathing difficulty, wheezing, dizziness, low blood pressure, swelling of the throat, tongue and face and loss of consciousness. It is life threatening and therefore constitutes a medical emergency. Apart from exposure to penicillin, people may get such a reaction from bee stings or if allergic to latex or peanuts. Treatment should be quick and include use of drugs such as epinephrine, antihistamines and corticosteroids.

Seasonal allergies occur as a result of exposure to airborne allergens during certain times of the year. A common allergen is pollen. Symptoms include runny nose, watery, itchy eyes and sneezing.

Redman syndrome is a rare condition which occurs a few minutes after receiving the drug vancomycin. Symptoms include redness or flushing of the face, neck and trunk. Dilution and slow infusion of the drug can help to prevent this reaction.

Stevens-Johnson syndrome is a potentially life threatening disorder affecting the skin and mucous membranes. It often begins with flu-like symptoms then the outermost layer of the skin progressively dies and sloughs off. Recovery may take weeks or months.

2. Although she regained consciousness, Mrs. X's face continued to swell and she became hoarse in spite of the treatment for her severe reaction to penicillin. Which of the following interventions is of highest priority in Mrs. X's case?

Answer: Keeping Mrs. X's airway patent

In a few cases of anaphylactic reactions, intubation may become necessary to protect the airway when the swelling is severe. Such a decision has to be timely because as swelling continues, intubation may become impossible. Swelling of the face is visible to the naked eye but swelling of the air passage is also taking place and cannot be readily seen. Hoarseness, pain with swallowing, coughing and a drop in the oxygen saturation on the bedside monitor are all signs the air passage is closing.

3. Mrs. X is orally intubated, on a ventilator and lightly sedated for comfort. She's unable to talk on account of the breathing tube but hopes the nurse can read her lips and understand what she's trying to communicate. When that fails, Mrs. X tries writing words with her finger in the air. At last, a frustrated Mrs. X begins to shake the bedrails vigorously. "You need to calm down!" says her nurse, "You have a tube in your mouth so I can't read your lips." The nurse promptly increases Mrs. X's sedation and applies soft restraints to her wrist. Instead of putting Mrs. X into a deep sleep what communication strategy might the nurse use in this case?

Answer: Any of these strategies may be used

Being unable to verbalize needs can be frustrating for the patient. The nurse can ease this frustration by trying to anticipate and meet the needs of the patient. She/he should also find ways to help the patient communicate. A sedated patient or one who's been on a ventilator for some time may be so deconditioned that when you give them a pen and paper, what is written looks like a pattern made by a roach that was immersed in ink and allowed to crawl freely on paper.

This should not frustrate the care giver. Alternative communication strategies should be employed.

Heavy sedation can contribute to extended ventilation time and increased risk of ventilator associated pneumonia.

4. Unfortunately for Mrs. X, she's still receiving ventilator support after 72 hours of intubation. A chest X-ray reveals bilateral infiltrates and doctor suspects she now has ventilator associated pneumonia (VAP). All of the following strategies can be employed to prevent VAP EXCEPT?

Answer: Keeping the head of bed flat

Many hospitals have put in place what's called a "ventilator bundle" to help reduce the incidence of VAP. This bundle comprises a group of evidence-based interventions which include (though not limited to) daily awakening and spontaneous breathing trials, oral care with chlorhexidine, regular changing of ventilator circuits, continuous subglottic suctioning, stress ulcer prophylaxis and elevation of the head of bed between 30 and 40 degrees.

The latter is in an attempt to prevent aspiration of gastric content.

5. Mrs. X took a turn for the worse. In addition to fever, she has a rapid heart rate and elevated white blood cell count. Culture of her sputum and blood reveals methicillin-resistant staphylococcus aureus (MRSA). Based on this information, what does Mrs. X now have?

Answer: Sepsis

Systemic inflammatory response syndrome (SIRS) is the presence of two or more of the following: abnormal body temperature, elevated heart rate, respiratory rate or WBC count. Sepsis is defined as SIRS in response to an infectious process. In the case of Mrs. X, MRSA was identified in her sputum and blood and she met three of four SIRS criteria. For this reason sepsis would be the most appropriate diagnosis. If the condition is allowed to progress, sepsis leads to septic shock and then multisystem organ dysfunction syndrome (MODS) in which organs or systems begin to fail.

Although MRSA infections can be difficult to treat due to broad spectrum resistance to antibiotics, a sensitivity study can help to identify which antibiotics can effectively work in each case. Influenza is a viral infection referred to as the flu. Hyperthyroidism is an endocrine disorder in which there's excess production of thyroid hormone.

6. Mrs. X's blood pressure begins to drop and she needs aggressive fluid resuscitation, revision of intravenous antibiotics and possibly vasoactive drugs. The doctor decides to insert a central venous catheter to facilitate treatment. During catheter insertion, the lung inadvertently gets punctured and a large pneumothorax (collection of air in the space surrounding the lung) results, causing the blood pressure to drop even further. Which of the following interventions is done to reverse the pneumothorax?

Answer: Insertion of a needle into the chest

Pneumothorax refers to a collection of air in the pleural cavity which surrounds the lungs. In some cases, a small pneumothorax will resolve on its own without treatment. On the other hand, air may continue to accumulate with every breath when there's a one-way valve allowing air to enter but not leave the pleural cavity. As air accumulates in the pleural cavity, the lung on the affected side begins to collapse progressively. The vital structures between the lungs, such as heart and aorta, get pushed towards the opposite lung. This lung too will collapse if the tension is allowed to build up unchecked (tension pneumothorax).

A tension pneumothorax is a clinical diagnosis. The patient manifests with acute shortness of breath, hypotension, tachycardia, absent breath sounds on the affected side, tracheal deviation away from the side of injury and altered level of consciousness. Tension pneumothorax is a medical emergency and its diagnosis demands immediate needle thoracostomy be performed. In this procedure a needle is inserted between the ribs in the upper chest on the affected side to allow an outlet for the air. Definitive treatment involves insertion of a chest tube for continuous drainage of air from the pleural space until the lung can fully re-expand.

7. Mrs. X has three vasopressors infusing to support her blood pressure which is being continuously monitored via an arterial line in her right groin. (Vasopressors work by causing constriction of blood vessels, which in turn raises the blood pressure). During his assessment of Mrs. X, the doctor observes that the right foot is colder than the left and the pulses much more difficult to palpate as well. Upon closer inspection, the sole of the right foot and the toes have started to have a purplish discoloration. What complication can arise from sustained use of vasopressors coupled with the presence of an arterial line?

Answer: Gangrene

Gangrene refers to tissue death as a result of inadequate blood supply. Being a diabetic puts Mrs. X at risk for peripheral vascular disease and efforts should be taken to avoid inserting an arterial line into a limb which already has vascular compromise. Even in the absence of preexisting vascular compromise however, vasopressors can cause reduction of blood flow to peripheral tissue in the extremities.

The presence of an arterial line in the lumen of the blood vessel causes a further reduction in blood flow to the extremity.

These conditions can predispose the patient to gangrene. Consequently, frequent checks should be made of any extremity which has an arterial line to observe for early signs of circulatory compromise. In this way, early interventions can be taken to prevent irreversible damage such as gangrene.

8. Mrs. X's nurse has been so busy that she doesn't realize that one of the drips being used to support the blood pressure has almost run out. She leaves Mrs. X in the care of another nurse and goes on her lunch break which is long overdue. The relief nurse is busy with her own patients and does not get a chance to peek into Mrs. X's room nor attend to alarms. The nurse returns from lunch to find Mrs. X's blood pressure dangerously low and the vital signs trend on the bedside monitor show that the pressure has been low for a long time. Which of these complications may arise from sustained low blood pressure?

Answer: Acute kidney injury

Acute kidney injury is a condition in which the kidneys suddenly lose the ability to filter harmful waste products from the blood. It may or may not be associated with diminished urinary output. Other clinical features include swelling of hands and feet, drowsiness, confusion, shortness of breath and seizures. Acute kidney injury is common in the critically ill patient and has a high mortality rate.

Some of the causes include diminished blood flow to the kidneys (as in sustained hypotension) which can cause acute tubular necrosis, use of certain drugs (for example ibuprofen, naproxen, Lisinopril, vancomycin, heroin, contrast media and certain cancer medications), anaphylaxis, and kidney trauma.

While some individuals may require dialysis for a short time, in some cases, damage to the kidney can be permanent.

9. It has been ten days since Mrs. X walked into hospital for treatment of a simple wound. Today she's on a ventilator and fighting a very bad infection. She now has generalized edema and greatly diminished urinary output following a period of sustained hypotension. A basic metabolic panel reveals elevated blood urea nitrogen and creatinine levels significantly above base line levels. Arterial blood gas interpretation suggests metabolic acidosis. Which specialist should be consulted to assist in Mrs. X's care?

Answer: Nephrologist

A nephrologist is a specialist in conditions affecting the kidneys. People suspected of having renal problems are referred to these doctors for comprehensive analysis and treatment. By analysis of clinical, biochemical and radiographic findings, a nephrologist can determine if the diminished urinary output in Mrs. X's case is due to decreased blood flow to the kidneys (pre renal), injury to the kidney itself (renal) or obstruction to the outflow of urine from the kidneys (post renal). Mrs. X does not have a history of previous kidney disease so her kidney injury is most likely a result of decreased effective circulating volume (hypotension) leading to acute tubular necrosis. The nephrologist is likely to recommend discontinuation of all nephrotoxic drugs and hemodialysis while the kidney gets time to heal. Dialysis does not have to be permanent.

A Cardiologist deals with conditions affecting the heart, an Oncologist specializes in cancers and a Neurologist specializes in conditions affecting the nervous system.

10. After a period of dialysis, miraculously, Mrs. X begins to show improvement and is systematically weaned off ventilator support and has the breathing tube removed. The infection has cleared from her blood and lungs. Mrs. X is later discharged home in seemingly good condition. Two weeks after discharge, Mrs. X is shopping in the mall when she suddenly has an attack of shortness of breath and chest pain and is rushed to hospital. Radiographic studies reveal accumulation of blood around the heart which has been punctured by a guide wire that was mistakenly left in during insertion of the central venous catheter. What is the accumulation of blood around the heart called?

Answer: Pericardial effusion

Pericardial effusion refers to accumulation of fluid in the pericardial sac surrounding the heart. Underlying causes of pericardial effusion include congestive heart failure, cancer, infection and injury to the pericardium. Although a small effusion may be asymptomatic, a large effusion can cause a buildup of pressure around the heart, preventing it from filling adequately during relaxation. Improper filling translates to reduced cardiac output, a drop in blood pressure, and hence inadequate blood supply to vital organs. Symptoms include shortness of breath, chest pain, dizziness and cold clammy skin and death.

When an effusion becomes large enough to exert pressure on the heart and impair ventricular filling it is referred to as cardiac tamponade, and is a medical emergency.

A pleural effusion refers to accumulation of fluid in the double layered lining surrounding the lungs (pleura). This may occur for example, in conditions such as congestive heart failure, lung or breast cancer, tuberculosis or liver failure. Because fluid is heavier that lung tissue, as it accumulates, the lung collapses causing the affected person to become short of breath.

Pleurisy is inflammation of the pleural sac surrounding the lungs. This makes breathing painful and may be associated with pleural effusion. Pericarditis refers to inflammation of the lining surrounding the heart.

Source: Author yency

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The Dark Side of Medicine Trivia Quiz

Medicine, when coupled with the right diagnosis usually has the power to heal. However, when Mrs. X is admitted to hospital for what she thought was a simple problem, she finds that the medicine is more malicious than her malady. Let's find out why.

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