Question of the Month

[جوري]

and the prize is>>>> just rep pts :hmm:
as usual think it over, do some research, but don't give me random guesses..chances are 20% in your favor.. so let me know your rational ..


A 72 year old diabetic man presents with fever,chills, burning micturition and altered mental status. He has a history of calcium oxalate renal stones and two previous episodes of lower urinary tract infections. He is being treated with Insulin for his diabetes. His pulse is 102/min BP 90/56 Temp 40c(104F) and RR 24. He is confused and disoriented. chest auscultation reveals diffuse bilateral crepitations. Chest radiography shows unilateral alveolar infiltration with prominent air brocheography. Labs show hematocrit of 35% WBC count of 15000/micrliter. platelet count of 100,000. Blood glucose of 110. Blood gas analysis shows shows ph of 7.4, pco2 of 28mmHG and paO2 of 49mmHG and PaO2 of 49mmHG. He is intubated and started on 100% O2 but his condition doesn't improve. He is suspected to be suffering ARDS (adults respiratory distress syndrome seondary to urosepsis. Which of the following suggests ARDS?

A- Normal pulmonary capillary wedge pressure
B-Increased lung compliance
C-Normal protein concentration and pulmonary edema
D-Normal pulmonary arterial pressure
E-Normal alveolar arterial PO2 gradient

good luck

[barney]

Normal Protein concentration. his urine looks ok, so he prolly hasnt got urosepsis.

(is he on any Antibiotics?)

[Khayal]

:sl:

B-Increased lung compliance

(Just a guess..:-[)

:w:

[Umm Yoosuf]

Assalaamu Alaikum Wa Rahmatulaah,

Tough question there...

I'm thinking maybe this one but not so sure.

C-Normal protein concentration and pulmonary edema


hmmm....

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[barney]

Yah, and the pulmonary odema points to the ARDS

[NoName55]

C
according what I could make out from my Wikipedia search (am I cheating)

[barney]

C
according what I could make out from my WIKIdpedia seach (am I cheatin')

Definatly!

[north_malaysian]

I'll choose

F: All of the above! :peace:

[جوري]

lol..
Jazakoum Allah..I appreciate all the replies.. I thought this would sink to the bottom unread :smile:..I think I'll ask you all for your rational that led you to choose your answer..will have to rep all of you just for making such a wonderful honest effort..but when I get my 'repability back' :embarrass

I can't give out the correct answer, until I learn your reason why..might also give you the chance to re-think or re-affirm your choice..


:w:

[Jayda]

hola,

is he on any antibiotics?

gracias

[north_malaysian]

Erm.. does that mean that I have to give reasons too for choosing answer "F".?:uuh:

[جوري]

By the way I just want to add, that you may use all the resources you need, it isn't cheating, it will be an educated thought but I'll need your rational ..and north malaysian you can't have all the above-- there is only one correct answer :smile:

[NoName55]

Definatly!

Definitely not! LOL

that was my pathetic attempt at sarcasm,
I think I should stop my attempts at humor since no one gets it.

[جوري]

hola,

is he on any antibiotics?

gracias

Just Insulin and 100% oxygen.. a general rule with Q's the info given is all the info needed :shade:


peace

[barney]

Whoo Yay! i'm a gonna get Rep from PA!!!

Rationale:
The Pulomenary odema is rsetricting bronchiol capacity. (hey i'm speedtyping, so no gags about me english please), NAD in the MSU sample points to no UTI being present.
He's old so is at increased risk of COAD and ARDS his resp is raised > 10 above nominal, and one side of his lung is flooded.

Sit him up, Give him a Cup of tea...He will be fine. Failing that, drain the chest, stick him on antibio's (WCC is down), fill him with a Diuretic and adjust his Metformin accordingly. QDS BM's and monitor.

Im a psychiatric nurse, but thats my best shot!

[north_malaysian]

and north malaysian you can't have all the above-- there is only one correct answer :smile:

Hey... I'm just thinking outside the box... that's why answer "F" exists... :exhausted

At least my answer is 20% correct...

[barney]

Definitely not! LOL

that was my pathetic attempt at sarcasm,
I think I should stop my attempts at humor since no one gets it.

Yeah i got it. Your sarcasm is traditionally pretty good. Lets not start arguing! there is a Patient DYING out there!:D

[جوري]

Whoo Yay! i'm a gonna get Rep from PA!!!

Rationale:
The Pulomenary odema is rsetricting bronchiol capacity. (hey i'm speedtyping, so no gags about me english please), NAD in the MSU sample points to no UTI being present.
He's old so is at increased risk of COAD and ARDS his resp is raised > 10 above nominal, and one side of his lung is flooded.

Sit him up, Give him a Cup of tea...He will be fine. Failing that, drain the chest, stick him on antibio's (WCC is down), fill him with a Diuretic and adjust his Metformin accordingly. QDS BM's and monitor.

Im a psychiatric nurse, but thats my best shot!

ok.. BUT, how the do you distinguish between ARDS and cardiogenic pulmonary edema?


cheers!

[barney]

Without Googeling i dont really know!
I imagine a MRI scan would show up the Cardio Pully odey-thingy. yeah...stick Him in a MRI and check for that.

[Jayda]

Just Insulin and 100% oxygen.. a general rule with Q's the info given is all the info needed :shade:


peace

gracias!

i have never done one of these questionaires before :) i would say C, but i am not a doctor...

maybe it would be best to consult his PCP or the attending physician... i do not know what the laws are in your country but in the united states this might be a breach of ethics... not that i imply you are in trouble, it just seems questionable and you might want to double check...

que Dios te bendiga

[NoName55]

Without Googeling i dont really know!
I imagine a MRI scan would show up the Cardio Pully odey-thingy. yeah...stick Him in a MRI and check for that.

Pulmonary edema refers to extravasation of fluid from the pulmonary vasculature into the interstitium and alveoli of the lung. The formation of pulmonary edema may be caused by 4 major pathophysiologic mechanisms: (1) imbalance of Starling forces (ie, increased pulmonary capillary pressure, decreased plasma oncotic pressure, increased negative interstitial pressure), (2) damage to the alveolar-capillary barrier, (3) lymphatic obstruction, and (4) idiopathic or unknown mechanism. Cardiogenic pulmonary edema (CPE) is defined as pulmonary edema due to increased capillary hydrostatic pressure secondary to elevated pulmonary venous pressure. CPE reflects the accumulation of fluid with a low-protein content in the lung interstitium and alveoli, when pulmonary veins and left atrium venous return exceeds left ventricular (LV) output.
Increased hydrostatic pressure leading to pulmonary edema may result from many causes, including excessive intravascular volume administration, pulmonary venous outflow obstruction (eg, mitral stenosis or left atrial myxoma), or LV failure secondary to systolic or diastolic dysfunction of the LV. CPE leads to progressive deterioration of alveolar gas exchange and respiratory failure. Without prompt recognition and treatment, patients' conditions can deteriorate rapidly.

Author: Ali A Sovari, MD, Staff Physician, Department of Internal Medicine, University of Illinois College of Medicine at Urbana-Champaign

[جوري]

Ans. is only one of the above :shade:

think about it over night :smile:

[barney]

So I was right with the Diuretics! (And the cup of tea ...cos thats a Diuretic 'n all) & the chest drain! and the sitting up!

Rep Please! :D

[جوري]

Hey... I'm just thinking outside the box... that's why answer "F" exists... :exhausted

At least my answer is 20% correct...

true :D

[جوري]

So I was right with the Diuretics! (And the cup of tea ...cos thats a Diuretic 'n all) & the chest drain! and the sitting up!

Rep Please! :D

The man has urosepsis and you want to put him on diuretics? At least in his state he can drift off into a coma and have a comfortable death..we shouldn't really hasten it..

I know the question seems deceptively simple but, it needs alot of thought...any wrong can do him in!

[barney]

Drat! I killed him. :(
i thought he hadnt actually got the UTI.

Time for me to pack up the doctoring and stick with the headshrinking.

[Woodrow]

I'm going to keep quiet about this one. I just want to say it is refreshing to see a thread that has not turned into a war zone.

However, I think I can give a hint is that one of the symptoms of ARDS is paradoxical as it is the opposite of what logic says should happen because of respiratory problems.

[جوري]

gracias!

you bet!

i have never done one of these questionaires before :) i would say C, but i am not a doctor...

Thankfully he isn't subject to our brain storming.. I do it every so often, I don't know if you have been following them in this section? every once in a while I'll make a question of the week or month thread-- to get people thinking about the complexity and fragility of the human body, not so much to have everyone playing doctor and also to get some to be interested in science if they are not sure what career they want to go into!

maybe it would be best to consult his PCP or the attending physician

This man is a hypothetical...his however isn't an uncommon condition and I am sure as such would consult with his attending!

... i do not know what the laws are in your country but in the united states this might be a breach of ethics

How so? They don't ban questions in the U.S I assure you..at least not yet!

... not that i imply you are in trouble, it just seems questionable and you might want to double check...

I am lost here..I am sorry!

que Dios te bendiga

Thank you?

cheers

[Jayda]

hola PurestAmbrosia!

i am sorry, i misunderstood this section, i thought it was n the advice section and was pertaining to a real life situation rather than a contest :) lol it has been a late night, my husband took me out dancing and i am feeling a little feint...

que Dios te bendiga (may God bless you)

[barney]

I think Jayda thought you were asking how to treat a real patient :D

@ woodrow, yeah it's refreshing, i'm still working out how to fit in some agnostical claptrap into the mix....but cant seem to do it :)

[جوري]

I'm going to keep quiet about this one. I just want to say it is refreshing to see a thread that has not turned into a war zone.

However, I think I can give a hint is that one of the symptoms of ARDS is paradoxical as it is the opposite of what logic says should happen because of respiratory problems.

:sl: akhi
My suspicion is you already know the answer to this one :D..but I am enjoying the turn out..I thought it would turn into that last cardio Q sinking sinking unnoticed lol
Al7mdlilah... I enjoyed this thread..want to see what else turns up with a reasonable why, before I give the final answer and once all the participants are done..

then maybe someone else can start a thread on their field of interest insha'Allah..
That way, everyone can teach each other something new..


:w:

[جوري]

I think Jayda thought you were asking how to treat a real patient :D

:lol:
the patients of the world would be in so much trouble if that is how their doctors went about it? :muddlehea

[barney]

Well one of our Docs diagnosed bucchettes by using Wikipedia :)

[جوري]

Well one of our Docs diagnosed bucchettes by using Wikipedia :)

Do you mean Behçet's? there is no such Dz as bucchettes at least none that I have ever come across..
I have a fairly good idea how medicine runs in England...no complains on the account that it is free and all.. but over here you can lose your license!
Doctors get free subscription to medical journals and latest data, why would they go looking into google or wiki?


cheers

[barney]

Yeah, thats the spelling.

The Doc in question is a bit of a loose cannon, he has access to the BMA sites , but prefers Wiki! Still a pretty good quack though.

[جوري]

^^^lol..
God save us...well it could be worst..
they just busted an anesthesiologist here who infected 5 of his pts with hepatitis..I'll take a wiki using quak over a dangerous criminal if I had to choose...

I don't know where this world is headed, but that is a topic for another day & another thread..

cheers

[جوري]

hola PurestAmbrosia!

i am sorry, i misunderstood this section, i thought it was n the advice section and was pertaining to a real life situation rather than a contest :) lol it has been a late night, my husband took me out dancing and i am feeling a little feint...

que Dios te bendiga (may God bless you)

peace..

thank you--I didn't see your response earlier, I apologize for lateness..

I hope you enjoyed you evening?
blessings to you as well

cheers...

[north_malaysian]

true :D

So, I'll get 20% of the prize ... right? :blind:

[جوري]

So, I'll get 20% of the prize ... right? :blind:

lol.. I thought I did rep you yesterday no?
will wait to the end of the day before giving out correct answer, maybe someone will give it another shot? :-\

:w:

[جوري]

first some visual aid to refer back to

this is an alveoli

what we use for pressure monitoring

insertion of cath. and reading on computer

Ok with that out of the way for reference we discuss what it is and why some of the answers are incorrect..

ARDS results from diffuse inflammatory injury to the lungs... Inflammatory mediators are recruited as a result of any local or distant injury. Once they become activated they release proteases and free oxygen radicals which in turns damages the alveolar and epithelial cells.
With that the alveolar capillary permeability increases understand that this system is under lock and key, once it is open like that protein is released the osmotic pressure increases pulling water into the alveoli. Accumulation of protein rich fluid results in diffuse alveolar damage... making the lungs stiff as in less compliant, less distensible, hence the increased lung complaince answer is wrong...Alveolar-Arterial PO2 difference is widened in ARDS and hypoxemia subsequently occurs largely to ventillation/perfusion mismatch.. you may read about that in more detail but what it means in a nut shell is either there is too much O2 trapped and can't get out or in as a result of a problem some where, it can also occur in emboli or clots etc.. anemia blood unable to unload O2 possibilities are endless but I digress ( there is also a way to calculate that to figure out what is causing the mismatch but that is too expansive for our purposes of this topic....
Anyhow the lungs a re a tricky organ, it works opposite of the entir body, and that I assure you is a fantastic feat of engineering sob7an Allah but that too is a topic for another day .. let's just say hypoxemia leads to vasoconstriction. Thus the pulmonary wedge pressure will be normal, and that is a major diffrentiating factor between ARDS and cardiogenic pulmonary edema. Pulmonary wedge pressure will be less than 18mmHG
also PaO2 to FiO2 ratio will be of 200mmHG

and the lungs will have a bilateral infiltrate although, that is a pretty nondescript finding..


thank you all for your time and participation


:w: