WBR288
| Author | [[PageAuthor::Gonzalo A. Romero, M.D. [1]]] |
|---|---|
| Exam Type | ExamType::USMLE Step 2 CK |
| Main Category | MainCategory::Surgery |
| Sub Category | SubCategory::Musculoskeletal/Rheumatology, SubCategory::Musculoskeletal/Rheumatology |
| Prompt | [[Prompt::A 72-year-old male falls at home and hits his right chest wall against the bed frame. He is brought to the ER after his wife called 911. His vitals are T 37C, 86 bpm, 21 respirations/min, BP: 126/80 mmHg. His head, eyes, ears, nose and throat are unremarkable. His carotid pulse is 2+ without bruits. His chest is symmetric with decreased expansion on the right side. Upon palpation he has exquisite tenderness over the eight right rib at the anterior axillary line level. His lungs are clear to auscultation and percussion bilaterally. The rest of the physical exam is unremarkable. A chest x-ray reveals a rib fracture and no other abnormal findings. Which of the following is the most appropriate management in this patient?]] |
| Answer A | AnswerA::Oral NSAIDs |
| Answer A Explanation | [[AnswerAExp::Incorrect. Oral NSAIDs may slightly control the pain associated with a plain rib fracture, but it is not enough to prevent the hypoventilation which could lead to pneumonia, specially in the elderly.]] |
| Answer B | AnswerB::Positive airway pressure |
| Answer B Explanation | [[AnswerBExp::Incorrect. It is used primarily in the treatment of sleep apnea.]] |
| Answer C | AnswerC::Observation |
| Answer C Explanation | [[AnswerCExp::Incorrect.]] |
| Answer D | AnswerD::Intercostal nerve block |
| Answer D Explanation | [[AnswerDExp::Correct.]] |
| Answer E | AnswerE::Oral narcotic therapy |
| Answer E Explanation | [[AnswerEExp::Incorrect. This can worsen the hypoventilation caused by the pain which can increase the risk of developing pneumonia.]] |
| Right Answer | RightAnswer::D |
| Explanation | [[Explanation::This elderly patient following a fall presents with a right 8th rib fracture which is limiting his right hemithorax expansion due to pain. The most appropriate management is local pain relief by nerve block and an epidural catheter and observe for 24 hours. If left untreated in the elderly, a rib fracture can cause splinting which leads to hypoventilation in the affected area. The potential hypoventilation could potentially lead to pneumonia.
A rib fracture can be complicated also with atelectasis and pulmnonary contusions. Educational Objective:
Educational Objective: |
| Approved | Approved::No |
| Keyword | WBRKeyword::Rib fracture, WBRKeyword::chest trauma, WBRKeyword::narcotics, WBRKeyword::intercostal nerve block |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |