Judgments
Cardiothoracic-Surgery.docx
Judgement of 27 pages for the course usmle at usmle (Cardiothoracic-S)
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Theme: ShockA Cardiogenic shock
B Hypovolaemic shock
C Neurogenic shock
D Septic shock
For each of the following situations, select the most likely answer from the above
list. Each option may be used once, more than once, or not at all.
Scenario 1
Incorrect
A 58-year-old male cyclist has been involved in a road traffic accident (RTA). He sustained an
open femoral fracture, with wound contamination and a severe thigh haematoma. Forty-eight
hours postexternal fixation, the patient is behaving aggressively on the ward and complaining of
pain in his leg. On examination, the patient is febrile with warm peripheries, tachycardic and
mildly hypotensive. The surgical site appears inflamed. The ECG shows a sinus tachycardia.
What type of shock is most likely?
D Correct answer
This patient is 48 hours postsurgery with an obvious source of infection – an open fracture with a
contaminated wound. He is displaying signs of shock with signs of vasodilatation – warm
peripheries. The most likely type of shock is septic shock.
Scenario 2
Incorrect
A 65-year-old diabetic woman is feeling generally unwell 4 days following an elective anterior
resection for a Dukes’ A colorectal carcinoma. On examination, the patient is afebrile,
tachycardic and hypotensive with clammy skin. Her abdomen is mildly tender with a clean dry
wound and scanty but audible bowel sounds. Her urine output has been poor for the last 6 hours.
The ECG shows a new left-bundle branch block. What type of shock is most likely?
A Correct answer
This patient has an important risk factor for ischaemic heart disease – diabetes mellitus – which
is associated with silent myocardial infarction. The patient feels generally unwell with signs of
shock and left-bundle branch block on the ECG. It is quite possible that the patient may have had
,a myocardial infarction and now presents with cardiogenic shock. The presence of bowel sounds
and a mildly tender abdomen suggest that an intra-abdominal problem is unlikely.
Scenario 3
Incorrect
A 44-year-old man with a short history of alcohol abuse presents with a 12-hour history of
persistent vomiting and abdominal pain following a drinking binge. On examination, the patient
has a low-grade pyrexia and is sweaty , tachypnoeic, tachycardic and hypotensive with cool
peripheries. Abdominal examination reveals marked epigastric tenderness. The chest radiograph
demonstrates a small left-pleural effusion, the abdominal radiograph shows two central distended
small bowel loops and the ECG shows a sinus tachycardia. What type of shock is most likely?
B Correct answer
This patient shows classical signs of significant hypovolaemia complicating alcohol-induced
acute pancreatitis. The circulating volume depletion can be attributed to a combination of
vomiting and third-space losses.
Theme: Thoracic trauma
A Aortic disruption
B Cardiac tamponade
C Diaphragmatic rupture
D Flail chest
E Haemothorax
F Massive haemothorax
G Myocardial contusion
H Oesophageal rupture
I Open pneumothorax
J Pulmonary contusion
K Simple pneumothorax
L Tension pneumothorax
M Tracheobronchial disruption
N Traumatic asphyxia
The following patients have all had thoracic injuries. Please select the most
appropriate diagnosis from the above list. The items may be used once, more than
once, or not at all.
, Scenario 1
Correct
A 26-year-old soldier is hit by shrapnel, resulting in a large defect to the left side of his chest. He
is brought to Casualty, the paramedics having securely occluded the defect on all sides with a
sterile dressing. On examination he is severely dyspnoeic, tachycardic and hypotensive. His
trachea is displaced to the right. Percussion reveals the left side of the chest to be hyper-resonant,
with decreased air entry on auscultation.
L Correct answer
L – Tension pneumothorax
Initially the patient suffers an open pneumothorax (‘sucking chest wound’), whereby the
equilibrium between intrathoracic pressure and atmospheric pressure is immediate; if the defect
is approximately two-thirds the tracheal width then the air follows the path of least resistance,
through the defect, impairing ventilation. The paramedics were correct to close the defect;
however, the dressing should only have been securely taped on three sides so as to create a
flutter-type valve effect; this ensures the dressing is sucked over the defect on inspiration
preventing air entering, while the open end allows air to escape on exhalation. By securing the
dressing on all sides, air progressively accumulates in the thoracic cavity, collapsing the lung on
the affected side. The mediastinum is displaced to the opposite side, decreasing venous return
and compressing the opposite lung. The most common cause of tension pneumothorax is
mechanical (positive-pressure) ventilation in the patient with a visceral pleural injury. Rapid
decompression is required to prevent death.
Scenario 2
Incorrect
A 65-year-old lady is brought to The Emergency Department having been involved in a road
traffic accident; it was a head-on collision in which she was the driver. Her signs are initially
stable, and examination only reveals bruising over and to the left of the sternum. A chest X-ray is
normal. A few hours later she develops an irregular tachycardia confirmed by electrocardiogram
to be atrial fibrillation.
G Correct answer
G – Myocardial contusion
Blunt thoracic trauma can result in cardiac injury: myocardial muscle contusion, cardiac chamber
rupture, or valvular disruption. Patients with myocardial contusion may complain of chest
discomfort but this is often attributed to chest wall contusion or fractures of the sternum and/or
ribs. The clinically important sequelae are hypotension, significant conduction abnormalities on
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