WBR0396

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Inpatient Facilities, MainCategory::Emergency Room
Sub Category	SubCategory::Infectious Disease, SubCategory::Cardiovascular, SubCategory::Infectious Disease, SubCategory::Obstetrics & Gynecology
Prompt	[[Prompt::A 31 year old woman who was 23 weeks pregnant presented with acute severe pain in her left buttock region radiating to the leg and increasing with ambulation. No underlying pathologies or drug abuse were present and no systemic symptoms were encountered. Backache was initially attributed to nerve compression. NSAID and rest were prescribed. After 4 days, the pain became worse. The patient appears to be warm and flushed. Physical examination further revealed a temperature of 39.2 C, pulse rate of 126 beats/minute, respiratory rate of 30 breaths/minute and blood pressure of 100/50mmHg. The laboratory test results were significant for leukocytes of 15400/mm3, hematocrit of 24%, D-Dimer of 946.8μg/L and platelet count of 85,000/mm3. Chest X-ray showed images of bilateral pulmonary condensation. A Swan-Ganz catheter is inserted and demonstrates increased cardiac output, decreased peripheral vascular resistance (vasodilation), and normal pulmonary capillary wedge pressure (PCWP). Which of the following is the most likely diagnosis?]]
Answer A	AnswerA::Late septic shock
Answer A Explanation	AnswerAExp::'''Incorrect'''-In late septic shock, patients become obtunded with decreased cardiac output and hypotension that is not reversible by volume replacement.
Answer B	AnswerB::Early septic shock
Answer B Explanation	[[AnswerBExp::Correct-The patient suffers form pyogenic sacroiliitis that has complicated into septic shock and DIC. The early phase of septic shock is characterized by vasodilation, resulting in a warm, flushed patient with a normal or elevated cardiac output, decreased peripheral vascular resistance, and normal pulmonary capillary wedge pressure. Fever, agitation, or confusion is often present.]]
Answer C	AnswerC::Cardiogenic shock
Answer C Explanation	[[AnswerCExp::Incorrect-Patients with cardiogenic shock have signs of pulmonary vascular congestion (Jugular venous distension, S3 gallop, bilateral lung crackles), increased pulmonary capillary wedge pressure (PCWP), and decreased cardiac output.]]
Answer D	AnswerD::Hypovolemic shock
Answer D Explanation	AnswerDExp::'''Incorrect'''-Hypovolemic shock is characterized by a physical examination consistent with volume depletion (tachycardia; hypotension; cool, clammy skin; poor capillary refill) and decreased PCWP.
Answer E	AnswerE::Neurogenic shock
Answer E Explanation	AnswerEExp::'''Incorrect'''-Neurogenic shock follows a spinal cord injury (warm skin, bradycardia, neurologic deficits) and is characterized by a decreased PCWP.
Right Answer	RightAnswer::B
Explanation	[[Explanation::The patient suffers form pyogenic sacroiliitis that has complicated into septic shock and DIC. The early phase of septic shock is characterized by vasodilation, resulting in a warm, flushed patient with a normal or elevated cardiac output, decreased peripheral vascular resistance, and normal pulmonary capillary wedge pressure. Fever, agitation, or confusion is often present. Educational Objective: Early septic shock can be differentiated from late septic shock by the presence of normal or elevated cardiac in early septic shock output when compared to decreased cardiac output in late septic shock. Decreased peripheral vascular resistance and normal pulmonary capillary wedge pressure will differentiate it from cardiogenic (increased PCWP), hypovolemic and neurogenic shock (decreased PCWP). Educational Objective: References: ]]
Approved	Approved::Yes
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