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  #1  
Old 05-31-2012
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Question USMLERx Questions Not Written Properly!

Hey every one, I just started doing USMLe rx and i feel like some question either are not written properly or i am not getting the information

2 months ago i did uworld and i was doing around 60%. I did DIT 2011, pathoma and now i am doing RX .i am doing 30-40% most of the times i am not understanding or misunderstanding the questions?
\Any one had similar experience?

!)A 28-year-old smoker presents to the emergency department because of sudden onset of chest pain and dyspnea at rest. His heart rate is 115/min, respiratory rate is 24/min, and blood pressure is 140/80 mm Hg in both arms. Lung examination shows decreased breath sounds and decreased fremitus on the right, with hyperresonance to percussion.

is this tension or Spontaneous ?
I picked Spontaneous because there is no history of trauma, his vitals are not that bad.
the correct answers is Tension p.
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  #2  
Old 05-31-2012
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Correct Answer USMLE Rx is right!

Correct Answer is Tension Pneumothorax (TP).
TP does not necessarily occur after trauma. It is merely a pneumothorax without an outlet for trapped air that causes cardiorespiratory compromise by compressing intrathoracic structures.
This patient with h/o smoking is likely to have an emphysematous bulla which may rupture spontaneously or after insignificant trauma such as a bout of coughing. If this bulla does not communicate with the outside or, as is the case in COPD, there is an expiratory obstruction it will form a TP.

Plus the clinical presentation is classic for TP.

Hope that helps!
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  #3  
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Quote:
Originally Posted by drssbaz View Post
Correct Answer is Tension Pneumothorax (TP).
TP does not necessarily occur after trauma. It is merely a pneumothorax without an outlet for trapped air that causes cardiorespiratory compromise by compressing intrathoracic structures.
This patient with h/o smoking is likely to have an emphysematous bulla which may rupture spontaneously or after insignificant trauma such as a bout of coughing. If this bulla does not communicate with the outside or, as is the case in COPD, there is an expiratory obstruction it will form a TP.

Plus the clinical presentation is classic for TP.

Hope that helps!
hey mate thanks for the replay.

Here is my question , How do u determine that it is Tension?
28 Male , smoker thats more of a spontaneous profile.
the vitals and the clinical exam is non specific. there is no history of smoking habits to indicate anything... in other words what is the hint in the question. Thank you
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Old 05-31-2012
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Originally Posted by budd View Post
hey mate thanks for the replay.

Here is my question , How do u determine that it is Tension?
28 Male , smoker thats more of a spontaneous profile.
the vitals and the clinical exam is non specific. there is no history of smoking habits to indicate anything... in other words what is the hint in the question. Thank you
I guess if tall and thin is missing you would go to tension?
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Old 05-31-2012
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I disagree

Points in favor of TP in the vignette:
-sudden onset of chest pain (Spontaneous)
-dyspnea at rest (Respiratory Distress)
-heart rate 115/min (Tachycardia)
-respiratory rate 24/min (Mild tachypnoea)
-blood pressure is 140/80 mm Hg in both arms (Possibly due to compression of aorta by the expanding pneumothorax)
Lung examination shows
-decreased breath sounds
-decreased fremitus on the right
-hyperresonance to percussion

Nothing else I know of fits this profile.
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Quote:
Originally Posted by drssbaz View Post
Points in favor of TP in the vignette:
-sudden onset of chest pain (Spontaneous)
-dyspnea at rest (Respiratory Distress)
-heart rate 115/min (Tachycardia)
-respiratory rate 24/min (Mild tachypnoea)
-blood pressure is 140/80 mm Hg in both arms (Possibly due to compression of aorta by the expanding pneumothorax)
Lung examination shows
-decreased breath sounds
-decreased fremitus on the right
-hyperresonance to percussion

Nothing else I know of fits this profile.
Every thing you mentioned fits SP.
-sudden onset of chest pain (Spontaneous)seen in both
-dyspnea at rest (Respiratory Distress) seen in both
-heart rate 115/min (Tachycardia) seen in both
-respiratory rate 24/min (Mild tachypnoea) seen in both,
-blood pressure is 140/80 mm Hg in both arms
well could be due to blood backing up and causing heart to push against more pressure

Lung examination shows
-decreased breath sounds seen in both
-decreased fremitus on the right seen in both
-hyperresonance to percussion seen in both

All the examinations are undefined...
I dont know how you could see that it only fits TP and not SP.
I think this question is not clear. there has to be one specific or multiple fact that put the pt in one or the other category.

There is no X ray given

How do u see that it does not fit SP... i would love to understand... I have looked up multiple sources ... I cant come to a conclusion.
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I disagree

I think you are confusing Open and Spontaneous Pneumothorax.
Only a Tension Pneumothorax presents like this, whether it is traumatic or spontaneous.

I've treated a lot of cases so I can tell that from experience as well.
I don't know how to make it clearer.

Hope you can find a satisfying answer somewhere. GL!
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Quote:
Originally Posted by drssbaz View Post
I think you are confusing Open and Spontaneous Pneumothorax.
Only a Tension Pneumothorax presents like this, whether it is traumatic or spontaneous.

I've treated a lot of cases so I can tell that from experience as well.
I don't know how to make it clearer.

Hope you can find a satisfying answer somewhere. GL!
ok

what is a classical presentation of Spontaneous Pneumothorax if you dont mind...
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Quote:
Originally Posted by budd View Post
ok

what is a classical presentation of Spontaneous Pneumothorax if you dont mind...
A "Spontaneous" Pneumothorax merely refers to how the pneumothorax develops.
The presentation will depend on a number of factors:
1. Size of the pneumothorax. A small pneumothorax will usually spontaneously resolve in 2-3weeks time.
2. Whether it has an outlet or not (i.e. is it open or not). If it is not then air & pressure will build up and develop TP.
Since TP is the one that underlies the most serious pathophysiology of Pneumothoraz viz. compression of intrathoracic structures, often rapidly and in a life threatening way, it is this presentation that is mostly associated with a pneumothorax and is considered most specific to it. It is TP that develops primarily due to air in the pleural space.
3. Underlying lung disease: In this case any type of pneumothorax may present with simply worsening of the underlying lung condition. In such a case even a small pneumothorax will require a chest tube. Here the pathology that is overwhelming is the pre-existing lung disease instead of merely air build up in the pleural space.

Ask me if something is still not clear. I was working in a busy trauma center for years so I'll try to clear your doubt to the best of my ability.
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Old 06-02-2012
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Quote:
Originally Posted by drssbaz View Post
A "Spontaneous" Pneumothorax merely refers to how the pneumothorax develops.
The presentation will depend on a number of factors:
1. Size of the pneumothorax. A small pneumothorax will usually spontaneously resolve in 2-3weeks time.
2. Whether it has an outlet or not (i.e. is it open or not). If it is not then air & pressure will build up and develop TP.
Since TP is the one that underlies the most serious pathophysiology of Pneumothoraz viz. compression of intrathoracic structures, often rapidly and in a life threatening way, it is this presentation that is mostly associated with a pneumothorax and is considered most specific to it. It is TP that develops primarily due to air in the pleural space.
3. Underlying lung disease: In this case any type of pneumothorax may present with simply worsening of the underlying lung condition. In such a case even a small pneumothorax will require a chest tube. Here the pathology that is overwhelming is the pre-existing lung disease instead of merely air build up in the pleural space.

Ask me if something is still not clear. I was working in a busy trauma center for years so I'll try to clear your doubt to the best of my ability.
According to your logic, it is a tension pneumothorax which developed spontaneously! So that makes it a Tension AND a Spontaneous pneumothorax. Is that correct?
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Originally Posted by eesfee View Post
According to your logic, it is a tension pneumothorax which developed spontaneously! So that makes it a Tension AND a Spontaneous pneumothorax. Is that correct?
Yes.
It is a Tension Pneumothorax that has developed spontaneously.
Or in other words a Spontaneous Pneumothorax that presents as Tension Pneumothorax. If it were a small one or communicating with a Bronchus it would not have become Tension Pneumothorax because then it would not have created enough pressure to compress the lungs, great vessels & heart.

It is not my logic, it is what I've learned from Chest & Trauma surgeons. I can't quote textbook though, it is merely practical knowledge you acquire while you practice. So can't tell you a definite source unless I ask someone.
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