🥵 HARD

Shock is about as scary as it is common.   There are several different types and so here at MedGuide we have written two sets of questions to quiz you on the presentation and schema of shock.  Good luck.

Second Author: Daniel Mercer

Reviewed by: awaiting review

Approach to the Patient with Shock

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Question 1

Stem 1 of 5

A 35YOF painter fell 8m from her ladder whilst working. She landed on her left side and presents with an open fracture of the anterior middle thigh. Her observations were: HR130, BP 95/60, RR24, T37.5ºC, sats 93% on air and 7.0mmol/L glucose reading. She is visibly distressed, unable to move her limb and there is a pool of blood from the open wound.

Which of the following structures, within the thigh, is most likely impinged given the mechanism of injury?
A
Common peroneal nerve
B
Great saphenous vein
C
Ilioinguinal nerve
D
Obturator nerve
E
Superficial fibular nerve
Question 1 Explanation: 
The great saphenous vein, running superficially in the anteromedial thigh, may be lacerated by bone shards given the site of injury. - Source: https://teachmeanatomy.info/lower-limb/vessels/venous-drainage/
Question 2

Stem 2 of 5

The patient opened her eyes when asked, she is upset but able to follow and contribute to a conversation. She can squeeze fingers and raise hands above the head appropriately. Calculate the patient’s Glasgow Coma Scale:
A
15
B
14
C
13
D
12
E
11
Question 2 Explanation: 
See how to calculate GCS rating here: https://www.mdcalc.com/glasgow-coma-scale-score-gcs
Question 3

Stem 3 of 5

What is the best-matched finding on physical examination?
A
Diminished dorsalis pedis pulse
B
Flushed, red skin of the lower limb
C
Grey-Turner and Cullen signs
D
Jugular venous pressure 6cm
E
Kussmaul breathing rate
Question 3 Explanation: 
>4cm is indicative of elevated JVP, not likely to be seen in this form of shock. Red skin is more akin to distributive shock. Kussmaul breathing is pathognomonic of diabetic ketoacidosis and Grey-Turner/Cullen signs of pancreatitis and retroperitoneal bleeding. Whilst the latter is a possibility in blunt force trauma, the diminished pulse of the lower limb - due to neurovascular complication of the thigh injury - is the better-matched answer given. Source: https://www.rcemlearning.co.uk/reference/shock/#1571062629589-b8c4ae31-adbf
Question 4

Stem 4 of 5

What is the most likely ABG finding for this patient?
A
Bicarbonate > 15 mmol/L
B
Glucose >4 mmol/L
C
K+ > 5.5 mmol/L
D
Lactate >2 mmol/L
E
Na+ > 140 mmol/L
Question 4 Explanation: 
An elevated serum lactate, measured by ABG, is a sensitive find of anaerobic metabolism indicative of end organ damage associated with the shocked patient. Source: http://www.oxfordmedicaleducation.com/abgs/abg-interpretation/
Question 5

Stem 5 of 5

What is the next best step if a bolus of IV 0.9% saline increases the patient’s blood pressure to 105/75?
A
Administer cross-matched blood
B
Give a intravenous beta blocker
C
Halt further fluid administration
D
Put the patient under general anesthetic
E
Repeat saline dosage
Question 5 Explanation: 
The patient has responded positively to an intravenous fluid bolus and is now in the range of permissive hypotension. In the short term, this is preferable for management, whilst the site(s) of bleeding are located and arrested.
Question 6

Stem 1 of 5

A 72YOF is admitted to the ward with ?urosepsis. Her obs are RR25, HR120, BP 90/60, 92% on air, T38.5ºC. On examination the patient is found confused, and combative beyond her baseline, as reported by collateral history with her carer.

Which of the following anatomical facts predispose this demography to the diagnosis?
A
A 4cm urethra
B
Benign prostatic hyperplasia
C
Horseshoe kidney abnormality
D
Overactive detrusor muscle
E
Renal artery stenosis
Question 6 Explanation: 
Revise the course of the sex-differentiated male and female urethra. In males the course of the urethra is not only more convoluted, but up to five times longer, than in females. This makes for a more challenging niche for bacterial colonisation. Source: https://teachmeanatomy.info/pelvis/viscera/urethra/
Question 7

Stem 2 of 5

24 hours later the patient presents with back pain, her temperature has increased to 39.5ºC with nausea and vomiting. What is the most appropriate investigation?
A
KUB CT scan
B
KUB ultrasound
C
MRI kidney
D
MSU cultures
E
Renal artery angiogram
Question 7 Explanation: 
NICE advises MSU cultures as the next best step for investigations
Question 8

Stem 3 of 5

Which of the following examination findings would most likely reinforce the diagnosis?
A
Further elevation of temperature
B
Palpable spleen in left iliac fossa
C
Passage of renal calculi (calcium oxalate)
D
Referred pain to the T5 dermatome
E
Tenderness of the costovertebral angle
Question 8 Explanation: 
This is where somatic sensation of the kidney is best felt when infected
Question 9

Stem 4 of 5

Which of the following organisms is more likely to be cultured in this patient?
A
Enterobacter species
B
Escherichia coli
C
Proteus mirablis
D
Pseudomonas species
E
Staphylococcus aureus
Question 9 Explanation: 
See NICE for most likely aetiology: https://cks.nice.org.uk/topics/pyelonephritis-acute/background-information/causes/
Question 10

Stem 5 of 5

The patient is given a two-week course of ceftriaxone. Which of the following side-effects are more likely given this course of treatment?
A
Colitis
B
Convulsions
C
Headache
D
Neuropathy
E
Pruritis
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