Q: 18 - 21

Q18: Rx Acidosis In Normovolemic Shock

Unlike other forms of shock, patients with septic shock are normovolemic with reasonable filling pressures.

The cardiac output is increased secondary to the hyperdynamic state induced by the sepsis.

The peripheral resistance is low and produces the paradoxical warm shock with pink dry extremities.

A low systemic vascular resistance is therefore most useful in establishing the diagnosis.

Most common is Gram Negative sepsis -- Hyperventilation, respiratory alkalosis, & AMS.

Q19: Rx Melanoma Thigh

Superficial Spreading. More commonly found on the

trunk, upper arms, and thighs. Most common form of

melanoma in white races. It begins a small pigmented

macule that is asymmetric, has irregular borders, and has color variations.

This type of melanoma remains in the flat phase for a shorter period of time than the lentigo maligna type before it penetrates into the deeper levels of the skin.

GenderWomen have a better prognosis likely due to

the fact that they acquire melanoma in more favorable locations (extremities)

Women are less likely to have ulcerated lesions

Necessary resection margins for melanoma

1cm… <1mm depth

2cm… 1-4mm depth

3cm… >4mm depth

TNM Classification

Lymph Nodes Remove all clinically positive lymph nodes Any lesion of 4mm or higher in thickness – LND is

controversial Intermediate thickness (1-4mm) with no evidence of

LN involvement – prophylactic LND is controversial Sentinel lymphadenectomy is gaining wide

acceptance as surgical modality for malignant melanoma Identifies the group of individual who may benefit from

LND

Q20: Rx / Dx Cardiac Tamponade

A 45-year old man is violently thrown against the steering wheel of his car during a high speed MVA. On arrival to the emergency department pt complains of chest pain and is visibly diaphoretic. His BP is 60/40 and RR=40. Which of the following would best allow you to delineate cardiac tamponade from tension pneumothorax as the cause of his hypotension? jugular venous pressurebreath soundspulse pressuretachycardia

Q20: Rx / Dx Cardiac Tamponade

breath sounds

Both cardiac tamponade and tension pneumothorax can present as hypotension, respiratory distress,and tachycardia, however tension pneumothorax classicaly presents with absent breath sounds and hyperresonance to percussion on the affected hemithorax.

Q20: Rx / Dx Cardiac Tamponade

Tamponade is almost invariably associated with widening of the mediastinal silhouette on the chest radiograph.

The association of rising atrial pressures, diminished cardiac output, and a widening mediastinum is sufficient to prompt surgical exploration.

Look for JVD, muffled heart sounds, and hypotension/decreased stroke volume (Beck's triad)

Q21: Natural Anatom Constriction ESOP.

Cricopharyngeus

Compression by the LEFT mainstem bronchus, and Aortic Arch

Diaphragm